|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 7071014831
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.81
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$7.14
|
|
|
Service Code
|
NDC 6068710011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.41
|
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.57
|
| Rate for Payer: Blue Shield of California Commercial |
$4.36
|
| Rate for Payer: Blue Shield of California EPN |
$3.48
|
| Rate for Payer: Cash Price |
$3.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.42
|
| Rate for Payer: Heritage Provider Network Senior |
$4.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.86
|
| Rate for Payer: TriValley Medical Group Senior |
$2.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.07
|
| Rate for Payer: Vantage Medical Group Senior |
$6.07
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 7071014831
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.63
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Senior |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 0527132601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.97
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$7.14
|
|
|
Service Code
|
NDC 6068710001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.57
|
| Rate for Payer: Blue Shield of California Commercial |
$4.36
|
| Rate for Payer: Blue Shield of California EPN |
$3.48
|
| Rate for Payer: Cash Price |
$3.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.42
|
| Rate for Payer: Heritage Provider Network Senior |
$4.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.86
|
| Rate for Payer: TriValley Medical Group Senior |
$2.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.07
|
| Rate for Payer: Vantage Medical Group Senior |
$6.07
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 0527132601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.75
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Senior |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$7.14
|
|
|
Service Code
|
NDC 6068710011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.60
|
| Rate for Payer: Cash Price |
$3.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.83
|
| Rate for Payer: Heritage Provider Network Senior |
$4.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$1.23
|
|
|
Service Code
|
NDC 0591315901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Senior |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.49
|
| Rate for Payer: TriValley Medical Group Senior |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$1.23
|
|
|
Service Code
|
NDC 0591315901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.79
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 4280650301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.97
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 4280650301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.75
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Senior |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
|
URSODIOL ORAL SUSPENSION COMPOUND 60 MG/ML [4080354]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 9994080354
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.75
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Senior |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
|
URSODIOL ORAL SUSPENSION COMPOUND 60 MG/ML [4080354]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 9994080354
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.97
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [215734]
|
Facility
|
IP
|
$102.72
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$77.04 |
| Rate for Payer: Adventist Health Commercial |
$20.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$66.15
|
| Rate for Payer: Cash Price |
$46.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$47.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.56
|
| Rate for Payer: Heritage Provider Network Senior |
$47.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.68
|
| Rate for Payer: Multiplan Commercial |
$77.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.01
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [215734]
|
Facility
|
OP
|
$102.72
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.36 |
| Max. Negotiated Rate |
$77.04 |
| Rate for Payer: Adventist Health Commercial |
$20.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$63.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$29.85
|
| Rate for Payer: Blue Shield of California Commercial |
$15.89
|
| Rate for Payer: Blue Shield of California EPN |
$15.89
|
| Rate for Payer: Cash Price |
$46.22
|
| Rate for Payer: Cash Price |
$46.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$47.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.74
|
| Rate for Payer: EPIC Health Plan Medicare |
$11.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.56
|
| Rate for Payer: Heritage Provider Network Senior |
$47.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$49.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15.22
|
| Rate for Payer: Multiplan Commercial |
$77.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$41.09
|
| Rate for Payer: TriValley Medical Group Senior |
$41.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.50
|
| Rate for Payer: Vantage Medical Group Senior |
$12.50
|
|
|
USTEKINUMAB 90 MG/ML SUBCUTANEOUS SYRINGE [108054]
|
Facility
|
IP
|
$36,730.84
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,648.28 |
| Max. Negotiated Rate |
$27,548.13 |
| Rate for Payer: Adventist Health Commercial |
$7,346.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23,654.66
|
| Rate for Payer: Cash Price |
$16,528.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16,896.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$19,834.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$17,006.38
|
| Rate for Payer: Heritage Provider Network Senior |
$17,006.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6,648.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9,182.71
|
| Rate for Payer: Multiplan Commercial |
$27,548.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13,270.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12,161.58
|
|
|
USTEKINUMAB 90 MG/ML SUBCUTANEOUS SYRINGE [108054]
|
Facility
|
OP
|
$36,730.84
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$263.49 |
| Max. Negotiated Rate |
$31,221.21 |
| Rate for Payer: Adventist Health Commercial |
$7,346.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22,699.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31,221.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20,201.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27,548.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$263.49
|
| Rate for Payer: Blue Shield of California Commercial |
$315.55
|
| Rate for Payer: Blue Shield of California EPN |
$315.55
|
| Rate for Payer: Cash Price |
$16,528.88
|
| Rate for Payer: Cash Price |
$16,528.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16,896.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31,221.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$31,221.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31,221.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$23,507.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$17,006.38
|
| Rate for Payer: Heritage Provider Network Senior |
$17,006.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17,520.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6,648.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9,182.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25,711.59
|
| Rate for Payer: Multiplan Commercial |
$27,548.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$14,692.34
|
| Rate for Payer: TriValley Medical Group Senior |
$14,692.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13,270.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12,161.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31,221.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31,221.21
|
| Rate for Payer: Vantage Medical Group Senior |
$31,221.21
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC
|
Facility
|
IP
|
$28,875.82
|
|
|
Service Code
|
MSDRG 742
|
| Min. Negotiated Rate |
$21,549.12 |
| Max. Negotiated Rate |
$28,875.82 |
| Rate for Payer: EPIC Health Plan Medicare |
$21,549.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21,549.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$24,781.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$28,875.82
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$19,753.11
|
|
|
Service Code
|
MSDRG 743
|
| Min. Negotiated Rate |
$14,741.13 |
| Max. Negotiated Rate |
$19,753.11 |
| Rate for Payer: EPIC Health Plan Medicare |
$14,741.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14,741.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16,952.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$19,753.11
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC
|
Facility
|
IP
|
$28,488.84
|
|
|
Service Code
|
MSDRG 740
|
| Min. Negotiated Rate |
$21,260.33 |
| Max. Negotiated Rate |
$28,488.84 |
| Rate for Payer: EPIC Health Plan Medicare |
$21,260.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21,260.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$24,449.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$28,488.84
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC
|
Facility
|
IP
|
$55,717.13
|
|
|
Service Code
|
MSDRG 739
|
| Min. Negotiated Rate |
$41,579.95 |
| Max. Negotiated Rate |
$55,717.13 |
| Rate for Payer: EPIC Health Plan Medicare |
$41,579.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$41,579.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$47,816.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$55,717.13
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$22,600.02
|
|
|
Service Code
|
MSDRG 741
|
| Min. Negotiated Rate |
$16,865.69 |
| Max. Negotiated Rate |
$22,600.02 |
| Rate for Payer: EPIC Health Plan Medicare |
$16,865.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16,865.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19,395.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22,600.02
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC
|
Facility
|
IP
|
$32,343.07
|
|
|
Service Code
|
MSDRG 737
|
| Min. Negotiated Rate |
$24,136.62 |
| Max. Negotiated Rate |
$32,343.07 |
| Rate for Payer: EPIC Health Plan Medicare |
$24,136.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24,136.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27,757.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32,343.07
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC
|
Facility
|
IP
|
$55,589.69
|
|
|
Service Code
|
MSDRG 736
|
| Min. Negotiated Rate |
$41,484.84 |
| Max. Negotiated Rate |
$55,589.69 |
| Rate for Payer: EPIC Health Plan Medicare |
$41,484.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$41,484.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$47,707.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$55,589.69
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$23,251.10
|
|
|
Service Code
|
MSDRG 738
|
| Min. Negotiated Rate |
$17,351.57 |
| Max. Negotiated Rate |
$23,251.10 |
| Rate for Payer: EPIC Health Plan Medicare |
$17,351.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17,351.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19,954.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23,251.10
|
|
