|
IRON SUCROSE 50 MG IRON/2.5 ML INTRAVENOUS SOLUTION [121793]
|
Facility
|
IP
|
$15.59
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$11.69 |
| Rate for Payer: Adventist Health Commercial |
$3.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.04
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.22
|
| Rate for Payer: Heritage Provider Network Senior |
$7.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$11.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.16
|
|
|
IRON SUCROSE 50 MG IRON/2.5 ML INTRAVENOUS SOLUTION [121793]
|
Facility
|
OP
|
$15.59
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$13.25 |
| Rate for Payer: Adventist Health Commercial |
$3.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.22
|
| Rate for Payer: Heritage Provider Network Senior |
$7.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.91
|
| Rate for Payer: Multiplan Commercial |
$11.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.24
|
| Rate for Payer: TriValley Medical Group Senior |
$6.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.25
|
| Rate for Payer: Vantage Medical Group Senior |
$13.25
|
|
|
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION [227445]
|
Facility
|
OP
|
$229.47
|
|
|
Service Code
|
HCPCS J9227
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.53 |
| Max. Negotiated Rate |
$172.10 |
| Rate for Payer: Adventist Health Commercial |
$45.89
|
| Rate for Payer: Adventist Health Commercial |
$45.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$141.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$141.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$132.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$132.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$96.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$96.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$88.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$88.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$161.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$161.52
|
| Rate for Payer: Blue Shield of California Commercial |
$80.73
|
| Rate for Payer: Blue Shield of California Commercial |
$80.73
|
| Rate for Payer: Blue Shield of California EPN |
$80.73
|
| Rate for Payer: Blue Shield of California EPN |
$80.73
|
| Rate for Payer: Cash Price |
$103.26
|
| Rate for Payer: Cash Price |
$103.26
|
| Rate for Payer: Cash Price |
$103.26
|
| Rate for Payer: Cash Price |
$103.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$105.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$105.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$110.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$110.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$96.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$96.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$146.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$146.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$88.16
|
| Rate for Payer: EPIC Health Plan Medicare |
$88.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$106.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$106.24
|
| Rate for Payer: Heritage Provider Network Senior |
$106.24
|
| Rate for Payer: Heritage Provider Network Senior |
$106.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$88.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$88.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$109.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$109.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$41.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$41.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$101.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$101.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$118.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$118.13
|
| Rate for Payer: Multiplan Commercial |
$172.10
|
| Rate for Payer: Multiplan Commercial |
$172.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$91.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$91.79
|
| Rate for Payer: TriValley Medical Group Senior |
$91.78
|
| Rate for Payer: TriValley Medical Group Senior |
$91.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$82.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$82.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$75.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$75.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$110.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$110.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.98
|
| Rate for Payer: Vantage Medical Group Senior |
$96.98
|
| Rate for Payer: Vantage Medical Group Senior |
$96.98
|
|
|
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION [227445]
|
Facility
|
IP
|
$229.46
|
|
|
Service Code
|
HCPCS J9227
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.53 |
| Max. Negotiated Rate |
$172.09 |
| Rate for Payer: Adventist Health Commercial |
$45.89
|
| Rate for Payer: Adventist Health Commercial |
$45.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$147.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$147.77
|
| Rate for Payer: Cash Price |
$103.26
|
| Rate for Payer: Cash Price |
$103.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$105.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$105.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$123.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$123.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$106.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$106.24
|
| Rate for Payer: Heritage Provider Network Senior |
$106.24
|
| Rate for Payer: Heritage Provider Network Senior |
$106.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$41.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$41.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.37
|
| Rate for Payer: Multiplan Commercial |
$172.10
|
| Rate for Payer: Multiplan Commercial |
$172.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$82.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$82.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$75.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$75.97
|
|
|
ISAVUCONAZONIUM SULFATE 186 MG CAPSULE [209331]
|
Facility
|
OP
|
$143.06
|
|
|
Service Code
|
NDC 0469052001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$121.60 |
| Rate for Payer: Adventist Health Commercial |
$28.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$88.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$121.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$78.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$107.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$71.56
|
| Rate for Payer: Blue Shield of California Commercial |
$87.27
|
| Rate for Payer: Blue Shield of California EPN |
$69.81
|
| Rate for Payer: Cash Price |
$64.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$92.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$121.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$121.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$121.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$91.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.55
|
| Rate for Payer: Heritage Provider Network Senior |
$88.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$68.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$100.14
|
| Rate for Payer: Multiplan Commercial |
$107.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$57.22
|
| Rate for Payer: TriValley Medical Group Senior |
$57.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$121.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$121.60
|
| Rate for Payer: Vantage Medical Group Senior |
$121.60
|
|
|
ISAVUCONAZONIUM SULFATE 186 MG CAPSULE [209331]
|
Facility
|
OP
|
$143.06
|
|
|
Service Code
|
NDC 0469052002
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$121.60 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$88.41
|
| Rate for Payer: Adventist Health Commercial |
$28.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$121.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$78.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$107.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$71.56
|
| Rate for Payer: Blue Shield of California Commercial |
$87.27
|
| Rate for Payer: Blue Shield of California EPN |
$69.81
|
| Rate for Payer: Cash Price |
$64.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$92.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$121.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$121.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$121.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$91.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.55
|
| Rate for Payer: Heritage Provider Network Senior |
$88.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$68.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$100.14
|
| Rate for Payer: Multiplan Commercial |
$107.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$57.22
|
| Rate for Payer: TriValley Medical Group Senior |
$57.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$121.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$121.60
|
| Rate for Payer: Vantage Medical Group Senior |
$121.60
|
|
|
ISAVUCONAZONIUM SULFATE 186 MG CAPSULE [209331]
|
Facility
|
IP
|
$143.06
|
|
|
Service Code
|
NDC 0469052002
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$107.30 |
| Rate for Payer: Adventist Health Commercial |
$28.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$92.13
|
| Rate for Payer: Cash Price |
$64.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$77.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$96.85
|
| Rate for Payer: Heritage Provider Network Senior |
$96.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.77
|
| Rate for Payer: Multiplan Commercial |
$107.30
|
|
|
ISAVUCONAZONIUM SULFATE 186 MG CAPSULE [209331]
|
Facility
|
IP
|
$143.06
|
|
|
Service Code
|
NDC 0469052001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$107.30 |
| Rate for Payer: Adventist Health Commercial |
$28.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$92.13
|
| Rate for Payer: Cash Price |
$64.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$77.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$96.85
|
| Rate for Payer: Heritage Provider Network Senior |
$96.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.77
|
| Rate for Payer: Multiplan Commercial |
$107.30
|
|
|
ISAVUCONAZONIUM SULFATE 372 MG INTRAVENOUS SOLUTION [209328]
|
Facility
|
OP
|
$487.45
|
|
|
Service Code
|
HCPCS J1833
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$365.59 |
| Rate for Payer: Adventist Health Commercial |
$97.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$301.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.57
|
| Rate for Payer: Blue Shield of California Commercial |
$1.05
|
| Rate for Payer: Blue Shield of California EPN |
$1.05
|
| Rate for Payer: Cash Price |
$219.35
|
| Rate for Payer: Cash Price |
$219.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$224.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$311.97
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$225.69
|
| Rate for Payer: Heritage Provider Network Senior |
$225.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$232.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$88.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$121.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$365.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$194.98
|
| Rate for Payer: TriValley Medical Group Senior |
$194.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$176.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$161.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Vantage Medical Group Senior |
$1.13
|
|
|
ISAVUCONAZONIUM SULFATE 372 MG INTRAVENOUS SOLUTION [209328]
|
Facility
|
IP
|
$487.45
|
|
|
Service Code
|
HCPCS J1833
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.23 |
| Max. Negotiated Rate |
$365.59 |
| Rate for Payer: Adventist Health Commercial |
$97.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$313.92
|
| Rate for Payer: Cash Price |
$219.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$224.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$263.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$225.69
|
| Rate for Payer: Heritage Provider Network Senior |
$225.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$88.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$121.86
|
| Rate for Payer: Multiplan Commercial |
$365.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$176.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$161.39
|
|
|
ISAVUCONAZONIUM SULFATE 74.5 MG CAPSULE [239551]
|
Facility
|
IP
|
$57.35
|
|
|
Service Code
|
NDC 0469286001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$43.01 |
| Rate for Payer: Adventist Health Commercial |
$11.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.93
|
| Rate for Payer: Cash Price |
$25.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.83
|
| Rate for Payer: Heritage Provider Network Senior |
$38.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.34
|
| Rate for Payer: Multiplan Commercial |
$43.01
|
|
|
ISAVUCONAZONIUM SULFATE 74.5 MG CAPSULE [239551]
|
Facility
|
OP
|
$57.35
|
|
|
Service Code
|
NDC 0469286001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$48.75 |
| Rate for Payer: Adventist Health Commercial |
$11.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$48.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$43.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.69
|
| Rate for Payer: Blue Shield of California Commercial |
$34.98
|
| Rate for Payer: Blue Shield of California EPN |
$27.99
|
| Rate for Payer: Cash Price |
$25.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$48.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.50
|
| Rate for Payer: Heritage Provider Network Senior |
$35.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$27.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$40.15
|
| Rate for Payer: Multiplan Commercial |
$43.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.94
|
| Rate for Payer: TriValley Medical Group Senior |
$22.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$28.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$48.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.75
|
| Rate for Payer: Vantage Medical Group Senior |
$48.75
|
|
|
ISAVUCONAZONIUM SULFATE 74.5 MG CAPSULE [239551]
|
Facility
|
IP
|
$57.35
|
|
|
Service Code
|
NDC 0469286035
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$43.01 |
| Rate for Payer: Adventist Health Commercial |
$11.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.93
|
| Rate for Payer: Cash Price |
$25.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.83
|
| Rate for Payer: Heritage Provider Network Senior |
$38.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.34
|
| Rate for Payer: Multiplan Commercial |
$43.01
|
|
|
ISAVUCONAZONIUM SULFATE 74.5 MG CAPSULE [239551]
|
Facility
|
OP
|
$57.35
|
|
|
Service Code
|
NDC 0469286035
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$48.75 |
| Rate for Payer: Adventist Health Commercial |
$11.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$48.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$43.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.69
|
| Rate for Payer: Blue Shield of California Commercial |
$34.98
|
| Rate for Payer: Blue Shield of California EPN |
$27.99
|
| Rate for Payer: Cash Price |
$25.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$48.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.50
|
| Rate for Payer: Heritage Provider Network Senior |
$35.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$27.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$40.15
|
| Rate for Payer: Multiplan Commercial |
$43.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.94
|
| Rate for Payer: TriValley Medical Group Senior |
$22.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$28.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$48.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.75
|
| Rate for Payer: Vantage Medical Group Senior |
$48.75
|
|
|
ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC
|
Facility
|
IP
|
$27,684.21
|
|
|
Service Code
|
MSDRG 062
|
| Min. Negotiated Rate |
$18,576.00 |
| Max. Negotiated Rate |
$27,684.21 |
| Rate for Payer: EPIC Health Plan Medicare |
$20,659.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20,659.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23,758.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$27,684.21
|
|
|
ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC
|
Facility
|
IP
|
$43,038.15
|
|
|
Service Code
|
MSDRG 061
|
| Min. Negotiated Rate |
$32,118.02 |
| Max. Negotiated Rate |
$43,038.15 |
| Rate for Payer: EPIC Health Plan Medicare |
$32,118.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$32,118.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$36,935.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$43,038.15
|
|
|
ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC
|
Facility
|
IP
|
$22,257.61
|
|
|
Service Code
|
MSDRG 063
|
| Min. Negotiated Rate |
$16,610.16 |
| Max. Negotiated Rate |
$22,257.61 |
| Rate for Payer: EPIC Health Plan Medicare |
$16,610.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16,610.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19,101.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22,257.61
|
|
|
ISONIAZID 100 MG TABLET [4026]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0555006602
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
ISONIAZID 100 MG TABLET [4026]
|
Facility
|
OP
|
$2.38
|
|
|
Service Code
|
NDC 8166510710
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.19
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.67
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Senior |
$0.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.02
|
| Rate for Payer: Vantage Medical Group Senior |
$2.02
|
|
|
ISONIAZID 100 MG TABLET [4026]
|
Facility
|
OP
|
$2.14
|
|
|
Service Code
|
NDC 6495021610
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.07
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California EPN |
$1.04
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Senior |
$1.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Senior |
$0.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.82
|
| Rate for Payer: Vantage Medical Group Senior |
$1.82
|
|
|
ISONIAZID 100 MG TABLET [4026]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0555006602
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
ISONIAZID 100 MG TABLET [4026]
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
NDC 8166510710
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.53
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
|
|
ISONIAZID 100 MG TABLET [4026]
|
Facility
|
IP
|
$2.14
|
|
|
Service Code
|
NDC 6495021610
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.38
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
IP
|
$4.68
|
|
|
Service Code
|
NDC 8166510830
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Adventist Health Commercial |
$0.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.01
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.17
|
| Rate for Payer: Heritage Provider Network Senior |
$3.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$3.51
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 6495021703
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.10
|
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Senior |
$2.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Senior |
$1.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
