|
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT [187503]
|
Facility
|
OP
|
$2,704.36
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.34 |
| Max. Negotiated Rate |
$2,028.27 |
| Rate for Payer: Adventist Health Commercial |
$540.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,671.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$240.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$176.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$160.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,300.50
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$1,216.96
|
| Rate for Payer: Cash Price |
$1,216.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,244.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$200.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$176.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$176.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,730.79
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,252.12
|
| Rate for Payer: Heritage Provider Network Senior |
$1,252.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,289.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$489.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$676.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.86
|
| Rate for Payer: Multiplan Commercial |
$2,028.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,081.74
|
| Rate for Payer: TriValley Medical Group Senior |
$1,081.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$977.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$895.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$200.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$176.37
|
| Rate for Payer: Vantage Medical Group Senior |
$176.37
|
|
|
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT [187503]
|
Facility
|
IP
|
$2,704.36
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$489.49 |
| Max. Negotiated Rate |
$2,028.27 |
| Rate for Payer: Adventist Health Commercial |
$540.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,741.61
|
| Rate for Payer: Cash Price |
$1,216.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,244.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,460.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,252.12
|
| Rate for Payer: Heritage Provider Network Senior |
$1,252.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$489.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$676.09
|
| Rate for Payer: Multiplan Commercial |
$2,028.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$977.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$895.41
|
|
|
LEUPROLIDE 7.5 MG (PED) INTRAMUSCULAR KIT [27123]
|
Facility
|
OP
|
$2,730.11
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.34 |
| Max. Negotiated Rate |
$2,047.58 |
| Rate for Payer: Cash Price |
$1,228.55
|
| Rate for Payer: Adventist Health Commercial |
$546.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,687.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$240.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$176.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$160.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,300.50
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$1,228.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,255.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$200.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$176.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$176.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,747.27
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,264.04
|
| Rate for Payer: Heritage Provider Network Senior |
$1,264.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,302.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$494.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$682.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.86
|
| Rate for Payer: Multiplan Commercial |
$2,047.58
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,092.04
|
| Rate for Payer: TriValley Medical Group Senior |
$1,092.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$986.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$903.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$200.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$176.37
|
| Rate for Payer: Vantage Medical Group Senior |
$176.37
|
|
|
LEUPROLIDE 7.5 MG (PED) INTRAMUSCULAR KIT [27123]
|
Facility
|
IP
|
$2,730.11
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$494.15 |
| Max. Negotiated Rate |
$2,047.58 |
| Rate for Payer: Adventist Health Commercial |
$546.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,758.19
|
| Rate for Payer: Cash Price |
$1,228.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,255.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,474.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,264.04
|
| Rate for Payer: Heritage Provider Network Senior |
$1,264.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$494.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$682.53
|
| Rate for Payer: Multiplan Commercial |
$2,047.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$986.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$903.94
|
|
|
LEUPROLIDE ACETATE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]
|
Facility
|
OP
|
$6,808.25
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,089.01 |
| Max. Negotiated Rate |
$5,106.19 |
| Rate for Payer: Adventist Health Commercial |
$1,361.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,207.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,301.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,025.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,025.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,089.01
|
| Rate for Payer: Blue Shield of California Commercial |
$1,749.65
|
| Rate for Payer: Blue Shield of California EPN |
$1,749.65
|
| Rate for Payer: Cash Price |
$3,063.71
|
| Rate for Payer: Cash Price |
$3,063.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,131.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,301.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,025.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,025.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,357.28
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,841.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,152.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3,152.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,841.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,247.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,232.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,117.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,702.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,467.29
|
| Rate for Payer: Multiplan Commercial |
$5,106.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,723.30
|
| Rate for Payer: TriValley Medical Group Senior |
$2,723.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,459.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,254.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,301.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,025.39
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.39
|
|
|
LEUPROLIDE ACETATE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]
|
Facility
|
IP
|
$6,808.25
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,232.29 |
| Max. Negotiated Rate |
$5,106.19 |
| Rate for Payer: Adventist Health Commercial |
$1,361.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,384.51
|
| Rate for Payer: Cash Price |
$3,063.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,131.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,676.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,152.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3,152.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,232.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,702.06
|
| Rate for Payer: Multiplan Commercial |
$5,106.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,459.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,254.21
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21045]
|
Facility
|
IP
|
$8,112.98
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,468.45 |
| Max. Negotiated Rate |
$6,084.73 |
| Rate for Payer: Adventist Health Commercial |
$1,622.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,224.76
|
| Rate for Payer: Cash Price |
$3,650.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,731.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,381.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,756.31
|
| Rate for Payer: Heritage Provider Network Senior |
$3,756.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,468.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,028.24
|
| Rate for Payer: Multiplan Commercial |
$6,084.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,931.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,686.21
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21045]
|
Facility
|
OP
|
$8,112.98
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.34 |
| Max. Negotiated Rate |
$6,084.73 |
| Rate for Payer: Adventist Health Commercial |
$1,622.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,013.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$240.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$176.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$160.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,300.50
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$3,650.84
|
| Rate for Payer: Cash Price |
$3,650.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,731.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$200.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$176.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$176.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,192.31
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,756.31
|
| Rate for Payer: Heritage Provider Network Senior |
$3,756.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,869.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,468.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,028.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.86
|
| Rate for Payer: Multiplan Commercial |
$6,084.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,245.19
|
| Rate for Payer: TriValley Medical Group Senior |
$3,245.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,931.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,686.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$200.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$176.37
|
| Rate for Payer: Vantage Medical Group Senior |
$176.37
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]
|
Facility
|
OP
|
$1,626.08
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.34 |
| Max. Negotiated Rate |
$1,300.50 |
| Rate for Payer: Vantage Medical Group Senior |
$176.37
|
| Rate for Payer: Adventist Health Commercial |
$325.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,004.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$240.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$176.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$160.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,300.50
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$731.74
|
| Rate for Payer: Cash Price |
$731.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$748.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$200.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$176.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$176.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,040.69
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$752.88
|
| Rate for Payer: Heritage Provider Network Senior |
$752.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$775.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$294.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$406.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.86
|
| Rate for Payer: Multiplan Commercial |
$1,219.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$650.43
|
| Rate for Payer: TriValley Medical Group Senior |
$650.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$587.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$538.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$200.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$176.37
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]
|
Facility
|
IP
|
$1,626.08
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$294.32 |
| Max. Negotiated Rate |
$1,219.56 |
| Rate for Payer: Adventist Health Commercial |
$325.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,047.20
|
| Rate for Payer: Cash Price |
$731.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$748.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$878.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$752.88
|
| Rate for Payer: Heritage Provider Network Senior |
$752.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$294.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$406.52
|
| Rate for Payer: Multiplan Commercial |
$1,219.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$587.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$538.40
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [153492]
|
Facility
|
OP
|
$16,226.27
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.34 |
| Max. Negotiated Rate |
$12,169.70 |
| Rate for Payer: Adventist Health Commercial |
$3,245.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10,027.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$240.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$176.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$160.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,300.50
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$7,301.82
|
| Rate for Payer: Cash Price |
$7,301.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,464.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$200.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$176.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$176.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,384.81
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,512.76
|
| Rate for Payer: Heritage Provider Network Senior |
$7,512.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,739.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,936.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,056.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.86
|
| Rate for Payer: Multiplan Commercial |
$12,169.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$6,490.51
|
| Rate for Payer: TriValley Medical Group Senior |
$6,490.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5,862.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5,372.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$200.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$176.37
|
| Rate for Payer: Vantage Medical Group Senior |
$176.37
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [153492]
|
Facility
|
IP
|
$16,226.27
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,936.95 |
| Max. Negotiated Rate |
$12,169.70 |
| Rate for Payer: Adventist Health Commercial |
$3,245.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10,449.72
|
| Rate for Payer: Cash Price |
$7,301.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,464.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,762.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,512.76
|
| Rate for Payer: Heritage Provider Network Senior |
$7,512.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,936.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,056.57
|
| Rate for Payer: Multiplan Commercial |
$12,169.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5,862.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5,372.52
|
|
|
LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0093414845
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
|
LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 0093414845
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
LEVALBUTEROL CONCENTRATE 1.25 MG/0.5 ML SOLUTION FOR NEBULIZATION (INTERMITTENT) [40856278]
|
Facility
|
OP
|
$6.43
|
|
|
Service Code
|
NDC 9940856978
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$5.47 |
| Rate for Payer: Adventist Health Commercial |
$1.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.22
|
| Rate for Payer: Blue Shield of California Commercial |
$3.92
|
| Rate for Payer: Blue Shield of California EPN |
$3.14
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.98
|
| Rate for Payer: Heritage Provider Network Senior |
$3.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.57
|
| Rate for Payer: TriValley Medical Group Senior |
$2.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.47
|
| Rate for Payer: Vantage Medical Group Senior |
$5.47
|
|
|
LEVALBUTEROL CONCENTRATE 1.25 MG/0.5 ML SOLUTION FOR NEBULIZATION (INTERMITTENT) [40856278]
|
Facility
|
IP
|
$6.43
|
|
|
Service Code
|
NDC 9940856978
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$4.82 |
| Rate for Payer: Adventist Health Commercial |
$1.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.14
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.35
|
| Rate for Payer: Heritage Provider Network Senior |
$4.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.61
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
|
|
LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154435]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
|
|
LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154435]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.73
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 3172257447
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 3172257447
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 7109314413
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 7109314413
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
LEVETIRACETAM 1,500 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154436]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
|
|
LEVETIRACETAM 1,500 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154436]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.73
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 6808485911
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
