|
VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [120259]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 8770140663
|
| Hospital Charge Code |
NDG120259B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
VIT E-GLYCERIN-DIMETHICONE LOTION [115875]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 299391808
|
| Hospital Charge Code |
NDG115875B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
VIT E-GLYCERIN-DIMETHICONE LOTION [115875]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 299391808
|
| Hospital Charge Code |
NDG115875B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
Vitrectomy, mechanical, pars plana approach;
|
Facility
|
OP
|
$9,652.00
|
|
|
Service Code
|
CPT 67036
|
| Min. Negotiated Rate |
$371.70 |
| Max. Negotiated Rate |
$9,652.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$371.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation
|
Facility
|
OP
|
$9,652.00
|
|
|
Service Code
|
CPT 67040
|
| Min. Negotiated Rate |
$270.07 |
| Max. Negotiated Rate |
$9,652.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$270.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation
|
Facility
|
OP
|
$9,652.00
|
|
|
Service Code
|
CPT 67039
|
| Min. Negotiated Rate |
$1,974.68 |
| Max. Negotiated Rate |
$9,652.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,974.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina (eg, for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil)
|
Facility
|
OP
|
$9,652.00
|
|
|
Service Code
|
CPT 67042
|
| Min. Negotiated Rate |
$293.87 |
| Max. Negotiated Rate |
$9,652.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$293.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker)
|
Facility
|
OP
|
$9,652.00
|
|
|
Service Code
|
CPT 67041
|
| Min. Negotiated Rate |
$1,284.13 |
| Max. Negotiated Rate |
$9,652.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,284.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (eg, choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and laser photocoagulation
|
Facility
|
OP
|
$9,652.00
|
|
|
Service Code
|
CPT 67043
|
| Min. Negotiated Rate |
$1,542.57 |
| Max. Negotiated Rate |
$9,652.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,054.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,542.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
VORICONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [38103]
|
Facility
|
IP
|
$12.83
|
|
|
Service Code
|
NDC 65162-913-22
|
| Hospital Charge Code |
1715204
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$9.62 |
| Rate for Payer: Adventist Health Commercial |
$2.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.81
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.69
|
| Rate for Payer: Heritage Provider Network Senior |
$8.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$9.62
|
|
|
VORICONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [38103]
|
Facility
|
IP
|
$8.20
|
|
|
Service Code
|
NDC 0049-3160-44
|
| Hospital Charge Code |
1715204
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Adventist Health Commercial |
$1.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.63
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.55
|
| Rate for Payer: Heritage Provider Network Senior |
$5.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.05
|
| Rate for Payer: Multiplan Commercial |
$6.15
|
|
|
VORICONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [38103]
|
Facility
|
OP
|
$8.20
|
|
|
Service Code
|
NDC 0049-3160-44
|
| Hospital Charge Code |
1715204
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$6.97 |
| Rate for Payer: Adventist Health Commercial |
$1.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.15
|
| Rate for Payer: Blue Shield of California Commercial |
$5.09
|
| Rate for Payer: Blue Shield of California EPN |
$4.81
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.97
|
| Rate for Payer: Dignity Health Senior |
$6.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.08
|
| Rate for Payer: Heritage Provider Network Senior |
$5.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.05
|
| Rate for Payer: Multiplan Commercial |
$6.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.28
|
| Rate for Payer: TriValley Medical Group Senior |
$3.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.97
|
| Rate for Payer: Vantage Medical Group Senior |
$6.97
|
|
|
VORICONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [38103]
|
Facility
|
OP
|
$12.83
|
|
|
Service Code
|
NDC 65162-913-22
|
| Hospital Charge Code |
1715204
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$10.91 |
| Rate for Payer: Adventist Health Commercial |
$2.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.62
|
| Rate for Payer: Blue Shield of California Commercial |
$7.97
|
| Rate for Payer: Blue Shield of California EPN |
$7.53
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.91
|
| Rate for Payer: Dignity Health Senior |
$10.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.94
|
| Rate for Payer: Heritage Provider Network Senior |
$7.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$9.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.13
|
| Rate for Payer: TriValley Medical Group Senior |
$5.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.91
|
| Rate for Payer: Vantage Medical Group Senior |
$10.91
|
|
|
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION [33010]
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
CPT J3465
|
| Hospital Charge Code |
1753462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Adventist Health Commercial |
$35.99
|
| Rate for Payer: Adventist Health Commercial |
$8.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$123.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$152.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$35.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$98.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$134.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.83
|
| Rate for Payer: Blue Shield of California Commercial |
$3.06
|
| Rate for Payer: Blue Shield of California Commercial |
$3.06
|
| Rate for Payer: Blue Shield of California Commercial |
$3.06
|
| Rate for Payer: Blue Shield of California EPN |
$3.06
|
| Rate for Payer: Blue Shield of California EPN |
$3.06
|
| Rate for Payer: Blue Shield of California EPN |
$3.06
|
| Rate for Payer: Cash Price |
$80.97
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$80.97
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$82.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$152.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$152.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.70
|
| Rate for Payer: Dignity Health Senior |
$152.94
|
| Rate for Payer: Dignity Health Senior |
$35.70
|
| Rate for Payer: Dignity Health Senior |
$61.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$115.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$83.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.34
|
| Rate for Payer: Heritage Provider Network Senior |
$33.34
|
| Rate for Payer: Heritage Provider Network Senior |
$83.31
|
| Rate for Payer: Heritage Provider Network Senior |
$19.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$86.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$34.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$134.95
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: Multiplan Commercial |
$31.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$28.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$71.97
|
| Rate for Payer: TriValley Medical Group Senior |
$71.97
|
| Rate for Payer: TriValley Medical Group Senior |
$28.80
|
| Rate for Payer: TriValley Medical Group Senior |
$16.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$65.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$60.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$152.94
|
| Rate for Payer: Vantage Medical Group Senior |
$152.94
|
| Rate for Payer: Vantage Medical Group Senior |
$35.70
|
| Rate for Payer: Vantage Medical Group Senior |
$61.20
|
|
|
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION [33010]
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
CPT J3465
|
| Hospital Charge Code |
1753462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.03 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Adventist Health Commercial |
$35.99
|
| Rate for Payer: Adventist Health Commercial |
$8.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$123.61
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$80.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$82.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$121.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.43
|
| Rate for Payer: Heritage Provider Network Senior |
$28.43
|
| Rate for Payer: Heritage Provider Network Senior |
$121.81
|
| Rate for Payer: Heritage Provider Network Senior |
$48.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: Multiplan Commercial |
$134.95
|
| Rate for Payer: Multiplan Commercial |
$31.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$65.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$60.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.03
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 65862-892-30
|
| Hospital Charge Code |
1711820
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$6.75 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.18
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.09
|
| Rate for Payer: Heritage Provider Network Senior |
$6.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 65862-892-30
|
| Hospital Charge Code |
1711820
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.75
|
| Rate for Payer: Blue Shield of California Commercial |
$5.59
|
| Rate for Payer: Blue Shield of California EPN |
$5.28
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.65
|
| Rate for Payer: Dignity Health Senior |
$7.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.57
|
| Rate for Payer: Heritage Provider Network Senior |
$5.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Senior |
$3.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.65
|
| Rate for Payer: Vantage Medical Group Senior |
$7.65
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 0049-3180-30
|
| Hospital Charge Code |
1711820
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Adventist Health Commercial |
$0.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.07
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.03
|
| Rate for Payer: Heritage Provider Network Senior |
$3.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$3.35
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$4.47
|
|
|
Service Code
|
NDC 0049-3180-30
|
| Hospital Charge Code |
1711820
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Adventist Health Commercial |
$0.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.35
|
| Rate for Payer: Blue Shield of California Commercial |
$2.78
|
| Rate for Payer: Blue Shield of California EPN |
$2.62
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.80
|
| Rate for Payer: Dignity Health Senior |
$3.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.77
|
| Rate for Payer: Heritage Provider Network Senior |
$2.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$3.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.79
|
| Rate for Payer: TriValley Medical Group Senior |
$1.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3.80
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 68462-573-30
|
| Hospital Charge Code |
1711820
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$6.75 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.18
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.09
|
| Rate for Payer: Heritage Provider Network Senior |
$6.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 68462-573-30
|
| Hospital Charge Code |
1711820
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.75
|
| Rate for Payer: Blue Shield of California Commercial |
$5.59
|
| Rate for Payer: Blue Shield of California EPN |
$5.28
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.65
|
| Rate for Payer: Dignity Health Senior |
$7.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.57
|
| Rate for Payer: Heritage Provider Network Senior |
$5.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Senior |
$3.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.65
|
| Rate for Payer: Vantage Medical Group Senior |
$7.65
|
|
|
VORICONAZOLE 50 MG TABLET [33008]
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
NDC 27241-062-03
|
| Hospital Charge Code |
1711819
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.79
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.76
|
| Rate for Payer: Heritage Provider Network Senior |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
|
|
VORICONAZOLE 50 MG TABLET [33008]
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
NDC 68462-572-30
|
| Hospital Charge Code |
1711819
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.79
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.76
|
| Rate for Payer: Heritage Provider Network Senior |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
|
|
VORICONAZOLE 50 MG TABLET [33008]
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 68462-572-30
|
| Hospital Charge Code |
1711819
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.95
|
| Rate for Payer: Blue Shield of California Commercial |
$1.61
|
| Rate for Payer: Blue Shield of California EPN |
$1.53
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.21
|
| Rate for Payer: Dignity Health Senior |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.04
|
| Rate for Payer: TriValley Medical Group Senior |
$1.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.21
|
| Rate for Payer: Vantage Medical Group Senior |
$2.21
|
|
|
VORICONAZOLE 50 MG TABLET [33008]
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 27241-062-03
|
| Hospital Charge Code |
1711819
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.95
|
| Rate for Payer: Blue Shield of California Commercial |
$1.61
|
| Rate for Payer: Blue Shield of California EPN |
$1.53
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.21
|
| Rate for Payer: Dignity Health Senior |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.04
|
| Rate for Payer: TriValley Medical Group Senior |
$1.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.21
|
| Rate for Payer: Vantage Medical Group Senior |
$2.21
|
|
