|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
IP
|
$5.37
|
|
|
Service Code
|
NDC 0168-0081-15
|
| Hospital Charge Code |
1743540
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$4.03 |
| Rate for Payer: Adventist Health Commercial |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.69
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.64
|
| Rate for Payer: Heritage Provider Network Senior |
$3.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$4.03
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
OP
|
$5.37
|
|
|
Service Code
|
NDC 0168-0081-15
|
| Hospital Charge Code |
1743540
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Adventist Health Commercial |
$1.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.69
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.03
|
| Rate for Payer: Blue Shield of California Commercial |
$3.33
|
| Rate for Payer: Blue Shield of California EPN |
$3.15
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.56
|
| Rate for Payer: Dignity Health Senior |
$4.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.32
|
| Rate for Payer: Heritage Provider Network Senior |
$3.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$4.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.56
|
| Rate for Payer: Vantage Medical Group Senior |
$4.56
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
IP
|
$7.16
|
|
|
Service Code
|
NDC 0472-0150-15
|
| Hospital Charge Code |
1743540
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$5.37 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.92
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.85
|
| Rate for Payer: Heritage Provider Network Senior |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$5.37
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
IP
|
$1.18
|
|
|
Service Code
|
NDC 51672-1263-2
|
| Hospital Charge Code |
1743543
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.81
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
OP
|
$7.16
|
|
|
Service Code
|
NDC 0472-0150-15
|
| Hospital Charge Code |
1743540
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$6.09 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.37
|
| Rate for Payer: Blue Shield of California Commercial |
$4.45
|
| Rate for Payer: Blue Shield of California EPN |
$4.20
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.09
|
| Rate for Payer: Dignity Health Senior |
$6.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.43
|
| Rate for Payer: Heritage Provider Network Senior |
$4.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$5.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.09
|
| Rate for Payer: Vantage Medical Group Senior |
$6.09
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
OP
|
$5.10
|
|
|
Service Code
|
NDC 0472-0150-30
|
| Hospital Charge Code |
1743543
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.82
|
| Rate for Payer: Blue Shield of California Commercial |
$3.17
|
| Rate for Payer: Blue Shield of California EPN |
$2.99
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.34
|
| Rate for Payer: Dignity Health Senior |
$4.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.16
|
| Rate for Payer: Heritage Provider Network Senior |
$3.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.34
|
| Rate for Payer: Vantage Medical Group Senior |
$4.34
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
OP
|
$1.68
|
|
|
Service Code
|
NDC 51672-1263-1
|
| Hospital Charge Code |
1743540
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$1.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$0.76
|
| 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 |
$0.81
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: Vantage Medical Group Senior |
$1.43
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
IP
|
$1.18
|
|
|
Service Code
|
NDC 68180-545-02
|
| Hospital Charge Code |
1743543
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.81
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
IP
|
$5.10
|
|
|
Service Code
|
NDC 0472-0150-30
|
| Hospital Charge Code |
1743543
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.50
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.45
|
| Rate for Payer: Heritage Provider Network Senior |
$3.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.82
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]
|
Facility
IP
|
$1.01
|
|
|
Service Code
|
NDC 68462-799-17
|
| Hospital Charge Code |
1743557
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.69
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]
|
Facility
OP
|
$1.01
|
|
|
Service Code
|
NDC 68462-799-17
|
| Hospital Charge Code |
1743557
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.86
|
| Rate for Payer: Dignity Health Senior |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Vantage Medical Group Senior |
$0.86
|
|
|
OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [204196]
|
Facility
OP
|
$233.26
|
|
|
Service Code
|
CPT J9301
|
| Hospital Charge Code |
NDG204196
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.22 |
| Max. Negotiated Rate |
$174.94 |
| Rate for Payer: Adventist Health Commercial |
$46.65
|
| Rate for Payer: Aetna of CA Gatekeeper |
$138.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$160.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$87.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$77.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$77.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$110.26
|
| Rate for Payer: Blue Shield of California Commercial |
$74.47
|
| Rate for Payer: Blue Shield of California EPN |
$74.47
|
| Rate for Payer: Cash Price |
$104.97
|
| Rate for Payer: Cash Price |
$104.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$107.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$105.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$77.38
|
| Rate for Payer: Dignity Health Senior |
$77.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$149.29
|
| Rate for Payer: EPIC Health Plan Medicare |
$70.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$108.00
|
| Rate for Payer: Heritage Provider Network Senior |
$108.00
|
| Rate for Payer: Humana Medicare |
$70.34
|
| Rate for Payer: IEHP Medi-Cal |
$116.69
|
| Rate for Payer: IEHP Medicare Advantage |
$70.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$133.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$83.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$88.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$88.63
|
| Rate for Payer: Multiplan Commercial |
$174.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$77.38
|
| Rate for Payer: TriValley Medical Group Senior |
$70.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$85.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$77.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$105.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$77.38
|
| Rate for Payer: Vantage Medical Group Senior |
$70.34
|
|
|
OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [204196]
|
Facility
IP
|
$233.26
|
|
|
Service Code
|
CPT J9301
|
| Hospital Charge Code |
NDG204196
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.22 |
| Max. Negotiated Rate |
$174.94 |
| Rate for Payer: Adventist Health Commercial |
$46.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$160.25
|
| Rate for Payer: Cash Price |
$104.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$107.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$125.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$157.92
|
| Rate for Payer: Heritage Provider Network Senior |
$157.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.32
|
| Rate for Payer: Multiplan Commercial |
$174.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$85.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$77.93
|
|
|
Observation Services for ER Services
|
Facility
OP
|
$2,276.00
|
|
| Min. Negotiated Rate |
$2,276.00 |
| Max. Negotiated Rate |
$2,276.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,276.00
|
|
|
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION [216963]
|
Facility
OP
|
$2,253.07
|
|
|
Service Code
|
CPT J2350
|
| Hospital Charge Code |
NDG216963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.75 |
| Max. Negotiated Rate |
$1,689.80 |
| Rate for Payer: Adventist Health Commercial |
$450.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$146.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,547.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$74.69
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$65.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$65.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$115.80
|
| Rate for Payer: Blue Shield of California Commercial |
$60.51
|
| Rate for Payer: Blue Shield of California EPN |
$60.51
|
| Rate for Payer: Cash Price |
$1,013.88
|
| Rate for Payer: Cash Price |
$1,013.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,036.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$65.73
|
| Rate for Payer: Dignity Health Senior |
$65.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,441.96
|
| Rate for Payer: EPIC Health Plan Medicare |
$59.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,043.17
|
| Rate for Payer: Heritage Provider Network Senior |
$1,043.17
|
| Rate for Payer: Humana Medicare |
$59.75
|
| Rate for Payer: IEHP Medi-Cal |
$100.17
|
| Rate for Payer: IEHP Medicare Advantage |
$59.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$113.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$407.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$70.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$563.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$75.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$75.29
|
| Rate for Payer: Multiplan Commercial |
$1,689.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$65.73
|
| Rate for Payer: TriValley Medical Group Senior |
$59.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$821.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$752.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$65.73
|
| Rate for Payer: Vantage Medical Group Senior |
$59.75
|
|
|
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION [216963]
|
Facility
IP
|
$2,253.07
|
|
|
Service Code
|
CPT J2350
|
| Hospital Charge Code |
NDG216963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$407.81 |
| Max. Negotiated Rate |
$1,689.80 |
| Rate for Payer: Adventist Health Commercial |
$450.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,547.86
|
| Rate for Payer: Cash Price |
$1,013.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,036.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,216.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,525.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1,525.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$407.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$563.27
|
| Rate for Payer: Multiplan Commercial |
$1,689.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$821.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$752.75
|
|
|
OCTREOTIDE ACETATE 1,000 MCG/ML INJECTION SOLUTION [91282]
|
Facility
IP
|
$119.25
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
NDG91282
|
|
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: Aetna of CA Non-Gatekeeper |
$81.92
|
| Rate for Payer: Cash Price |
$53.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$80.73
|
| Rate for Payer: Heritage Provider Network Senior |
$80.73
|
| 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 |
$43.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.84
|
|
|
OCTREOTIDE ACETATE 1,000 MCG/ML INJECTION SOLUTION [91282]
|
Facility
OP
|
$119.25
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
NDG91282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$101.36 |
| Rate for Payer: Adventist Health Commercial |
$23.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$81.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$101.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$65.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$89.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Cash Price |
$53.66
|
| Rate for Payer: Cash Price |
$53.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.86
|
| 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: IEHP Medi-Cal |
$8.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$57.48
|
| 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 |
$43.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.84
|
| 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
IP
|
$7.80
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
1720587
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$5.85 |
| Rate for Payer: Adventist Health Commercial |
$1.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.36
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.28
|
| Rate for Payer: Heritage Provider Network Senior |
$5.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.61
|
|
|
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]
|
Facility
OP
|
$7.80
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
1720587
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Adventist Health Commercial |
$1.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.63
|
| Rate for Payer: Dignity Health Senior |
$6.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.61
|
| Rate for Payer: Heritage Provider Network Senior |
$3.61
|
| Rate for Payer: IEHP Medi-Cal |
$8.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.63
|
| Rate for Payer: Vantage Medical Group Senior |
$6.63
|
|
|
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION [91281]
|
Facility
IP
|
$59.63
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
1720585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.79 |
| Max. Negotiated Rate |
$44.72 |
| Rate for Payer: Adventist Health Commercial |
$11.93
|
| Rate for Payer: Adventist Health Commercial |
$2.58
|
| Rate for Payer: Adventist Health Commercial |
$8.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.97
|
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$26.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.73
|
| Rate for Payer: Heritage Provider Network Senior |
$8.73
|
| Rate for Payer: Heritage Provider Network Senior |
$28.43
|
| Rate for Payer: Heritage Provider Network Senior |
$40.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.33
|
| 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 |
$10.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.91
|
| Rate for Payer: Multiplan Commercial |
$44.72
|
| Rate for Payer: Multiplan Commercial |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$9.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.92
|
|
|
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION [91281]
|
Facility
OP
|
$42.00
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
1720585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.86 |
| 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 |
$2.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$50.69
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$35.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$44.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$31.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$26.83
|
| Rate for Payer: Cash Price |
$26.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.70
|
| Rate for Payer: Dignity Health Senior |
$35.70
|
| Rate for Payer: Dignity Health Senior |
$10.96
|
| Rate for Payer: Dignity Health Senior |
$50.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.97
|
| Rate for Payer: Heritage Provider Network Senior |
$19.45
|
| Rate for Payer: Heritage Provider Network Senior |
$27.61
|
| Rate for Payer: Heritage Provider Network Senior |
$5.97
|
| Rate for Payer: IEHP Medi-Cal |
$8.81
|
| Rate for Payer: IEHP Medi-Cal |
$8.81
|
| Rate for Payer: IEHP Medi-Cal |
$8.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.22
|
| 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 |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$44.72
|
| Rate for Payer: Multiplan Commercial |
$9.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.70
|
| Rate for Payer: Vantage Medical Group Senior |
$35.70
|
| Rate for Payer: Vantage Medical Group Senior |
$50.69
|
| Rate for Payer: Vantage Medical Group Senior |
$10.96
|
|
|
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION [91278]
|
Facility
OP
|
$5.40
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
1720586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.59
|
| Rate for Payer: Dignity Health Senior |
$4.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: IEHP Medi-Cal |
$8.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.60
|
| 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: Multiplan Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$4.59
|
|
|
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION [91278]
|
Facility
IP
|
$5.40
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
1720586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.71
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.66
|
| Rate for Payer: Heritage Provider Network Senior |
$3.66
|
| 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: Multiplan Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.80
|
|
|
OCTREOTIDE,MICROSPHERES 20 MG INTRAMUSCULAR WRAP, LONG-ACTING RELEASE [40824435]
|
Facility
IP
|
$5,324.45
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX24435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$963.73 |
| Max. Negotiated Rate |
$3,993.34 |
| Rate for Payer: Adventist Health Commercial |
$1,064.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,657.90
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,449.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,875.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,604.65
|
| Rate for Payer: Heritage Provider Network Senior |
$3,604.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$963.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,331.11
|
| Rate for Payer: Multiplan Commercial |
$3,993.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,941.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,778.90
|
|
