|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 60687-800-40
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Senior |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 60687-800-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 0121-0868-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Senior |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 0121-0868-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 9999-0537-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| 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 Senior |
$0.19
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 0121-0868-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 60687-800-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Senior |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 0904-7276-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 0121-1045-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 0121-0868-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: Dignity Health Senior |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
|
IP
|
$1.68
|
|
|
Service Code
|
NDC 51672-1263-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Senior |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
|
OP
|
$1.68
|
|
|
Service Code
|
NDC 51672-1263-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.82
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.43
|
| Rate for Payer: Dignity Health Senior |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Senior |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.18
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.67
|
| Rate for Payer: TriValley Medical Group Senior |
$0.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: Vantage Medical Group Senior |
$1.43
|
|
|
OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [204196]
|
Facility
|
IP
|
$270.01
|
|
|
Service Code
|
HCPCS J9301
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.87 |
| Max. Negotiated Rate |
$202.51 |
| Rate for Payer: Adventist Health Commercial |
$54.00
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$124.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$125.01
|
| Rate for Payer: Heritage Provider Network Senior |
$125.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.50
|
| Rate for Payer: Multiplan Commercial |
$202.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$97.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$89.40
|
|
|
OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [204196]
|
Facility
|
OP
|
$270.01
|
|
|
Service Code
|
HCPCS J9301
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.87 |
| Max. Negotiated Rate |
$223.06 |
| Rate for Payer: Adventist Health Commercial |
$54.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$144.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$185.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$86.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$86.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$223.06
|
| Rate for Payer: Blue Shield of California Commercial |
$84.06
|
| Rate for Payer: Blue Shield of California EPN |
$84.06
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$124.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$98.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$86.31
|
| Rate for Payer: Dignity Health Senior |
$86.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$172.81
|
| Rate for Payer: EPIC Health Plan Medicare |
$78.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$125.01
|
| Rate for Payer: Heritage Provider Network Senior |
$125.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$75.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$78.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$128.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$90.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$98.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$98.86
|
| Rate for Payer: Multiplan Commercial |
$202.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$108.00
|
| Rate for Payer: TriValley Medical Group Senior |
$108.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$97.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$89.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$98.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$86.31
|
| Rate for Payer: Vantage Medical Group Senior |
$86.31
|
|
|
OCTREOTIDE ACETATE 1,000 MCG/ML INJECTION SOLUTION [91282]
|
Facility
|
IP
|
$119.25
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.58 |
| Max. Negotiated Rate |
$89.44 |
| Rate for Payer: Adventist Health Commercial |
$23.85
|
| Rate for Payer: Cash Price |
$65.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.21
|
| Rate for Payer: Heritage Provider Network Senior |
$55.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.81
|
| Rate for Payer: Multiplan Commercial |
$89.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.48
|
|
|
OCTREOTIDE ACETATE 1,000 MCG/ML INJECTION SOLUTION [91282]
|
Facility
|
OP
|
$119.25
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$101.36 |
| Rate for Payer: Adventist Health Commercial |
$23.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$63.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$81.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$101.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$65.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$89.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Cash Price |
$65.59
|
| Rate for Payer: Cash Price |
$65.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$101.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$101.36
|
| Rate for Payer: Dignity Health Senior |
$101.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.21
|
| Rate for Payer: Heritage Provider Network Senior |
$55.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$56.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$83.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$83.47
|
| Rate for Payer: Multiplan Commercial |
$89.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$47.70
|
| Rate for Payer: TriValley Medical Group Senior |
$47.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$101.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$101.36
|
| Rate for Payer: Vantage Medical Group Senior |
$101.36
|
|
|
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]
|
Facility
|
OP
|
$3.90
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Adventist Health Commercial |
$1.56
|
| Rate for Payer: Adventist Health Commercial |
$2.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Cash Price |
$6.56
|
| Rate for Payer: Cash Price |
$4.29
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cash Price |
$6.56
|
| Rate for Payer: Cash Price |
$4.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.63
|
| Rate for Payer: Dignity Health Senior |
$6.63
|
| Rate for Payer: Dignity Health Senior |
$10.14
|
| Rate for Payer: Dignity Health Senior |
$3.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.81
|
| Rate for Payer: Heritage Provider Network Senior |
$3.61
|
| Rate for Payer: Heritage Provider Network Senior |
$5.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.35
|
| Rate for Payer: Multiplan Commercial |
$8.95
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.77
|
| Rate for Payer: TriValley Medical Group Senior |
$4.77
|
| Rate for Payer: TriValley Medical Group Senior |
$3.12
|
| Rate for Payer: TriValley Medical Group Senior |
$1.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.63
|
| Rate for Payer: Vantage Medical Group Senior |
$10.14
|
| Rate for Payer: Vantage Medical Group Senior |
$6.63
|
| Rate for Payer: Vantage Medical Group Senior |
$3.31
|
|
|
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]
|
Facility
|
IP
|
$3.90
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Adventist Health Commercial |
$2.39
|
| Rate for Payer: Adventist Health Commercial |
$1.56
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cash Price |
$4.29
|
| Rate for Payer: Cash Price |
$6.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.81
|
| Rate for Payer: Heritage Provider Network Senior |
$1.81
|
| Rate for Payer: Heritage Provider Network Senior |
$5.52
|
| Rate for Payer: Heritage Provider Network Senior |
$3.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
| Rate for Payer: Multiplan Commercial |
$8.95
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.29
|
|
|
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION [91281]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$35.70 |
| Rate for Payer: Adventist Health Commercial |
$8.40
|
| Rate for Payer: Adventist Health Commercial |
$11.93
|
| Rate for Payer: Adventist Health Commercial |
$4.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$31.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$35.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$50.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$44.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.69
|
| Rate for Payer: Dignity Health Senior |
$50.69
|
| Rate for Payer: Dignity Health Senior |
$19.89
|
| Rate for Payer: Dignity Health Senior |
$35.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.45
|
| Rate for Payer: Heritage Provider Network Senior |
$27.61
|
| Rate for Payer: Heritage Provider Network Senior |
$10.83
|
| Rate for Payer: Heritage Provider Network Senior |
$19.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$29.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$41.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$41.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.38
|
| Rate for Payer: Multiplan Commercial |
$17.55
|
| Rate for Payer: Multiplan Commercial |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$44.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$23.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.36
|
| Rate for Payer: TriValley Medical Group Senior |
$9.36
|
| Rate for Payer: TriValley Medical Group Senior |
$23.85
|
| Rate for Payer: TriValley Medical Group Senior |
$16.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$50.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.69
|
| Rate for Payer: Vantage Medical Group Senior |
$19.89
|
| Rate for Payer: Vantage Medical Group Senior |
$50.69
|
| Rate for Payer: Vantage Medical Group Senior |
$35.70
|
|
|
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION [91281]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.60 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Adventist Health Commercial |
$8.40
|
| Rate for Payer: Adventist Health Commercial |
$4.68
|
| Rate for Payer: Adventist Health Commercial |
$11.93
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.45
|
| Rate for Payer: Heritage Provider Network Senior |
$19.45
|
| Rate for Payer: Heritage Provider Network Senior |
$10.83
|
| Rate for Payer: Heritage Provider Network Senior |
$27.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.91
|
| Rate for Payer: Multiplan Commercial |
$44.72
|
| Rate for Payer: Multiplan Commercial |
$17.55
|
| Rate for Payer: Multiplan Commercial |
$31.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.91
|
|
|
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION [91278]
|
Facility
|
OP
|
$5.40
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Adventist Health Commercial |
$0.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.59
|
| Rate for Payer: Dignity Health Senior |
$2.96
|
| Rate for Payer: Dignity Health Senior |
$4.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.78
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$2.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.39
|
| Rate for Payer: TriValley Medical Group Senior |
$1.39
|
| Rate for Payer: TriValley Medical Group Senior |
$2.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$2.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4.59
|
|
|
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION [91278]
|
Facility
|
IP
|
$3.48
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.61 |
| Rate for Payer: Adventist Health Commercial |
$0.70
|
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$2.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.15
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 70756-609-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 70756-609-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2.20
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Senior |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.52
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
OFLOXACIN 0.3 % EYE DROPS [19746]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 70756-607-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2.20
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Senior |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.52
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
