|
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION [36151]
|
Facility
OP
|
$1,567.88
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
ERX36151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.80 |
| Max. Negotiated Rate |
$1,175.91 |
| Rate for Payer: Adventist Health Commercial |
$313.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$96.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,077.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$49.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$43.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$43.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.80
|
| Rate for Payer: Blue Shield of California Commercial |
$41.52
|
| Rate for Payer: Blue Shield of California EPN |
$41.52
|
| Rate for Payer: Cash Price |
$705.55
|
| Rate for Payer: Cash Price |
$705.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$721.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.40
|
| Rate for Payer: Dignity Health Senior |
$43.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,003.44
|
| Rate for Payer: EPIC Health Plan Medicare |
$39.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$725.93
|
| Rate for Payer: Heritage Provider Network Senior |
$725.93
|
| Rate for Payer: Humana Medicare |
$39.46
|
| Rate for Payer: IEHP Medi-Cal |
$68.52
|
| Rate for Payer: IEHP Medicare Advantage |
$39.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$74.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$283.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$46.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$391.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$49.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$49.72
|
| Rate for Payer: Multiplan Commercial |
$1,175.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.40
|
| Rate for Payer: TriValley Medical Group Senior |
$39.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$571.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$523.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$59.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.40
|
| Rate for Payer: Vantage Medical Group Senior |
$39.46
|
|
|
OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE [223364]
|
Facility
IP
|
$1,567.87
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
NDG223364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$283.78 |
| Max. Negotiated Rate |
$1,175.90 |
| Rate for Payer: Adventist Health Commercial |
$313.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,077.13
|
| Rate for Payer: Cash Price |
$705.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$721.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$846.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,061.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1,061.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$283.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$391.97
|
| Rate for Payer: Multiplan Commercial |
$1,175.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$571.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$523.83
|
|
|
OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE [223364]
|
Facility
OP
|
$1,567.87
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
NDG223364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.80 |
| Max. Negotiated Rate |
$1,175.90 |
| Rate for Payer: Adventist Health Commercial |
$313.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$96.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,077.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$49.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$43.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$43.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.80
|
| Rate for Payer: Blue Shield of California Commercial |
$41.52
|
| Rate for Payer: Blue Shield of California EPN |
$41.52
|
| Rate for Payer: Cash Price |
$705.54
|
| Rate for Payer: Cash Price |
$705.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$721.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.40
|
| Rate for Payer: Dignity Health Senior |
$43.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,003.44
|
| Rate for Payer: EPIC Health Plan Medicare |
$39.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$725.92
|
| Rate for Payer: Heritage Provider Network Senior |
$725.92
|
| Rate for Payer: Humana Medicare |
$39.46
|
| Rate for Payer: IEHP Medi-Cal |
$68.52
|
| Rate for Payer: IEHP Medicare Advantage |
$39.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$74.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$283.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$46.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$391.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$49.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$49.72
|
| Rate for Payer: Multiplan Commercial |
$1,175.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.40
|
| Rate for Payer: TriValley Medical Group Senior |
$39.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$571.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$523.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$59.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.40
|
| Rate for Payer: Vantage Medical Group Senior |
$39.46
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
OP
|
$3.65
|
|
|
Service Code
|
NDC 60687-127-11
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Adventist Health Commercial |
$0.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.74
|
| Rate for Payer: Blue Shield of California Commercial |
$2.27
|
| Rate for Payer: Blue Shield of California EPN |
$2.14
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.10
|
| Rate for Payer: Dignity Health Senior |
$3.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.26
|
| Rate for Payer: Heritage Provider Network Senior |
$2.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$2.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.10
|
| Rate for Payer: Vantage Medical Group Senior |
$3.10
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
IP
|
$3.65
|
|
|
Service Code
|
NDC 60687-127-11
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Adventist Health Commercial |
$0.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.51
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.47
|
| Rate for Payer: Heritage Provider Network Senior |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$2.74
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
IP
|
$3.65
|
|
|
Service Code
|
NDC 60687-127-65
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Adventist Health Commercial |
$0.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.51
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.47
|
| Rate for Payer: Heritage Provider Network Senior |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$2.74
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
OP
|
$3.65
|
|
|
Service Code
|
NDC 60687-127-65
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Adventist Health Commercial |
$0.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.74
|
| Rate for Payer: Blue Shield of California Commercial |
$2.27
|
| Rate for Payer: Blue Shield of California EPN |
$2.14
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.10
|
| Rate for Payer: Dignity Health Senior |
$3.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.26
|
| Rate for Payer: Heritage Provider Network Senior |
$2.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$2.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.10
|
| Rate for Payer: Vantage Medical Group Senior |
$3.10
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
IP
|
$0.27
|
|
|
Service Code
|
NDC 64380-761-11
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| 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 |
$0.20
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
IP
|
$0.97
|
|
|
Service Code
|
NDC 60505-3170-7
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.67
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Senior |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
OP
|
$0.27
|
|
|
Service Code
|
NDC 64380-761-11
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| 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 |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
OP
|
$0.97
|
|
|
Service Code
|
NDC 60505-3170-7
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.73
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.57
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: Dignity Health Senior |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
|
|
OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE [10774]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 1191710202
|
| Hospital Charge Code |
1712604
|
|
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 Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE [10774]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 1191710202
|
| Hospital Charge Code |
1712604
|
|
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 Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
OMEGA-3 FATTY ACIDS 1,000 MG CAPSULE [31828]
|
Facility
IP
|
$0.06
|
|
|
Service Code
|
NDC 1093933733
|
| Hospital Charge Code |
1712605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
OMEGA-3 FATTY ACIDS 1,000 MG CAPSULE [31828]
|
Facility
OP
|
$0.06
|
|
|
Service Code
|
NDC 1093933733
|
| Hospital Charge Code |
1712605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
OMEPRAZOLE MAGNESIUM 20 MG TABLET,DELAYED RELEASE [36205]
|
Facility
OP
|
$0.86
|
|
|
Service Code
|
NDC 37000-459-02
|
| Hospital Charge Code |
ERX36205
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Senior |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
OMEPRAZOLE MAGNESIUM 20 MG TABLET,DELAYED RELEASE [36205]
|
Facility
IP
|
$0.86
|
|
|
Service Code
|
NDC 37000-459-02
|
| Hospital Charge Code |
ERX36205
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]
|
Facility
OP
|
$760.80
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
1721073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.33 |
| Max. Negotiated Rate |
$570.60 |
| Rate for Payer: Adventist Health Commercial |
$152.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$522.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.42
|
| Rate for Payer: Blue Shield of California Commercial |
$6.47
|
| Rate for Payer: Blue Shield of California EPN |
$6.47
|
| Rate for Payer: Cash Price |
$342.36
|
| Rate for Payer: Cash Price |
$342.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$349.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.96
|
| Rate for Payer: Dignity Health Senior |
$6.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$486.91
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$352.25
|
| Rate for Payer: Heritage Provider Network Senior |
$352.25
|
| Rate for Payer: Humana Medicare |
$6.33
|
| Rate for Payer: IEHP Medi-Cal |
$16.83
|
| Rate for Payer: IEHP Medicare Advantage |
$6.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$137.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$190.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.97
|
| Rate for Payer: Multiplan Commercial |
$570.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.96
|
| Rate for Payer: TriValley Medical Group Senior |
$6.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$277.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$254.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: Vantage Medical Group Senior |
$6.33
|
|
|
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]
|
Facility
IP
|
$760.80
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
1721073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.70 |
| Max. Negotiated Rate |
$570.60 |
| Rate for Payer: Adventist Health Commercial |
$152.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$522.67
|
| Rate for Payer: Cash Price |
$342.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$349.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$410.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$515.06
|
| Rate for Payer: Heritage Provider Network Senior |
$515.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$137.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$190.20
|
| Rate for Payer: Multiplan Commercial |
$570.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$277.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$254.18
|
|
|
ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION [95794]
|
Facility
OP
|
$420.00
|
|
|
Service Code
|
NDC 0023-3919-50
|
| Hospital Charge Code |
ERX95794
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.02 |
| Max. Negotiated Rate |
$357.00 |
| Rate for Payer: Adventist Health Commercial |
$84.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$224.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$288.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$357.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$231.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$315.00
|
| Rate for Payer: Blue Shield of California Commercial |
$260.82
|
| Rate for Payer: Blue Shield of California EPN |
$246.54
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$193.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$357.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$357.00
|
| Rate for Payer: Dignity Health Senior |
$357.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$268.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$194.46
|
| Rate for Payer: Heritage Provider Network Senior |
$194.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$202.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.00
|
| Rate for Payer: Multiplan Commercial |
$315.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$153.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$140.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$357.00
|
| Rate for Payer: Vantage Medical Group Senior |
$357.00
|
|
|
ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION [95794]
|
Facility
IP
|
$420.00
|
|
|
Service Code
|
NDC 0023-3919-50
|
| Hospital Charge Code |
ERX95794
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.02 |
| Max. Negotiated Rate |
$315.00 |
| Rate for Payer: Adventist Health Commercial |
$84.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$288.54
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$193.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$226.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$284.34
|
| Rate for Payer: Heritage Provider Network Senior |
$284.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.00
|
| Rate for Payer: Multiplan Commercial |
$315.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$153.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$140.32
|
|
|
ONASEMNOGENE ABEPARVOVEC-XIOI 2 X 10EXP13 VG/ML IV SUSPENSION,KIT [224879]
|
Facility
IP
|
$35,465.93
|
|
|
Service Code
|
CPT J3399
|
| Hospital Charge Code |
ERX224879
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,419.33 |
| Max. Negotiated Rate |
$26,599.45 |
| Rate for Payer: Adventist Health Commercial |
$7,093.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24,365.09
|
| Rate for Payer: Cash Price |
$15,959.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16,314.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$19,151.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$24,010.43
|
| Rate for Payer: Heritage Provider Network Senior |
$24,010.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,419.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8,866.48
|
| Rate for Payer: Multiplan Commercial |
$26,599.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12,930.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11,849.17
|
|
|
ONASEMNOGENE ABEPARVOVEC-XIOI 2 X 10EXP13 VG/ML IV SUSPENSION,KIT [224879]
|
Facility
OP
|
$35,465.93
|
|
|
Service Code
|
CPT J3399
|
| Hospital Charge Code |
ERX224879
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,419.33 |
| Max. Negotiated Rate |
$5,737,493.94 |
| Rate for Payer: Adventist Health Commercial |
$7,093.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18,956.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24,365.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,774,667.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,321,707.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,321,707.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,541,346.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,167,500.00
|
| Rate for Payer: Blue Shield of California EPN |
$2,167,500.00
|
| Rate for Payer: Cash Price |
$15,959.67
|
| Rate for Payer: Cash Price |
$15,959.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16,314.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,529,600.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,321,707.02
|
| Rate for Payer: Dignity Health Senior |
$3,321,707.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$22,698.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,019,733.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$16,420.73
|
| Rate for Payer: Heritage Provider Network Senior |
$16,420.73
|
| Rate for Payer: Humana Medicare |
$3,019,733.65
|
| Rate for Payer: IEHP Medicare Advantage |
$3,019,733.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,737,493.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,419.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,563,285.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8,866.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,804,864.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,804,864.40
|
| Rate for Payer: Multiplan Commercial |
$26,599.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,321,707.02
|
| Rate for Payer: TriValley Medical Group Senior |
$3,019,733.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12,930.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11,849.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,529,600.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,321,707.02
|
| Rate for Payer: Vantage Medical Group Senior |
$3,019,733.65
|
|
|
ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]
|
Facility
OP
|
$0.55
|
|
|
Service Code
|
NDC 68462-157-40
|
| Hospital Charge Code |
1711782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: Dignity Health Senior |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
|
ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]
|
Facility
IP
|
$0.73
|
|
|
Service Code
|
NDC 62756-240-64
|
| Hospital Charge Code |
1711782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.50
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
|
