|
CLOZAPINE 25 MG TABLET [9648]
|
Facility
IP
|
$0.78
|
|
|
Service Code
|
NDC 51079-921-01
|
| Hospital Charge Code |
1712217
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| 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 Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
CLOZAPINE 25 MG TABLET [9648]
|
Facility
IP
|
$0.78
|
|
|
Service Code
|
NDC 51079-921-20
|
| Hospital Charge Code |
1712217
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| 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 Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
CLOZAPINE 25 MG TABLET [9648]
|
Facility
IP
|
$0.79
|
|
|
Service Code
|
NDC 60687-404-01
|
| Hospital Charge Code |
1712217
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| 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 Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
CLOZAPINE 25 MG TABLET [9648]
|
Facility
OP
|
$0.79
|
|
|
Service Code
|
NDC 60687-404-11
|
| Hospital Charge Code |
1712217
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.67
|
| Rate for Payer: Dignity Health Senior |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| 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 Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
|
|
CLOZAPINE 25 MG TABLET [9648]
|
Facility
OP
|
$0.78
|
|
|
Service Code
|
NDC 51079-921-20
|
| Hospital Charge Code |
1712217
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.66
|
| Rate for Payer: Dignity Health Senior |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Vantage Medical Group Senior |
$0.66
|
|
|
CLOZAPINE 25 MG TABLET [9648]
|
Facility
OP
|
$0.79
|
|
|
Service Code
|
NDC 60687-404-01
|
| Hospital Charge Code |
1712217
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.67
|
| Rate for Payer: Dignity Health Senior |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| 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 Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
|
|
CLOZAPINE 50 MG TABLET [41637]
|
Facility
IP
|
$1.58
|
|
|
Service Code
|
NDC 0093-4404-01
|
| Hospital Charge Code |
ERX41637
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.09
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.07
|
| Rate for Payer: Heritage Provider Network Senior |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
|
|
CLOZAPINE 50 MG TABLET [41637]
|
Facility
OP
|
$1.58
|
|
|
Service Code
|
NDC 0093-4404-01
|
| Hospital Charge Code |
ERX41637
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.93
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.34
|
| Rate for Payer: Dignity Health Senior |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.98
|
| Rate for Payer: Heritage Provider Network Senior |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: Vantage Medical Group Senior |
$1.34
|
|
|
COAGULATION AND PLATELET DISORDERS
|
Facility
IP
|
$10,572.76
|
|
|
Service Code
|
APR-DRG 6613
|
| Min. Negotiated Rate |
$10,572.76 |
| Max. Negotiated Rate |
$10,572.76 |
| Rate for Payer: IEHP Medi-Cal |
$10,572.76
|
|
|
COAGULATION AND PLATELET DISORDERS
|
Facility
IP
|
$20,138.68
|
|
|
Service Code
|
APR-DRG 6614
|
| Min. Negotiated Rate |
$20,138.68 |
| Max. Negotiated Rate |
$20,138.68 |
| Rate for Payer: IEHP Medi-Cal |
$20,138.68
|
|
|
COAGULATION AND PLATELET DISORDERS
|
Facility
IP
|
$6,144.48
|
|
|
Service Code
|
APR-DRG 6611
|
| Min. Negotiated Rate |
$6,144.48 |
| Max. Negotiated Rate |
$6,144.48 |
| Rate for Payer: IEHP Medi-Cal |
$6,144.48
|
|
|
COAGULATION AND PLATELET DISORDERS
|
Facility
IP
|
$8,184.01
|
|
|
Service Code
|
APR-DRG 6612
|
| Min. Negotiated Rate |
$8,184.01 |
| Max. Negotiated Rate |
$8,184.01 |
| Rate for Payer: IEHP Medi-Cal |
$8,184.01
|
|
|
COAGULATION FACTOR IX (RECOMB) 1,000 UNIT INTRAVENOUS SOLUTION [203437]
|
Facility
IP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX19814
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.33
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
|
|
COAGULATION FACTOR IX (RECOMB) 1,000 UNIT INTRAVENOUS SOLUTION [203437]
|
Facility
OP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX19814
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.52
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: Dignity Health Senior |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Humana Medicare |
$1.75
|
| Rate for Payer: IEHP Medicare Advantage |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$1.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.93
|
| Rate for Payer: TriValley Medical Group Senior |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.75
|
|
|
COAGULATION FACTOR IX (RECOMB) 2,000 UNIT INTRAVENOUS SOLUTION [203438]
|
Facility
OP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX203438
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.52
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: Dignity Health Senior |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Humana Medicare |
$1.75
|
| Rate for Payer: IEHP Medicare Advantage |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$1.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.93
|
| Rate for Payer: TriValley Medical Group Senior |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.75
|
|
|
COAGULATION FACTOR IX (RECOMB) 2,000 UNIT INTRAVENOUS SOLUTION [203438]
|
Facility
IP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX203438
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.33
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
|
|
COAGULATION FACTOR IX (RECOMB) 250 UNIT INTRAVENOUS SOLUTION [203435]
|
Facility
OP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX203435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.52
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: Dignity Health Senior |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Humana Medicare |
$1.75
|
| Rate for Payer: IEHP Medicare Advantage |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$1.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.93
|
| Rate for Payer: TriValley Medical Group Senior |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.75
|
|
|
COAGULATION FACTOR IX (RECOMB) 250 UNIT INTRAVENOUS SOLUTION [203435]
|
Facility
IP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX203435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.33
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
|
|
COAGULATION FACTOR IX (RECOMB) 3,000 UNIT INTRAVENOUS SOLUTION [203439]
|
Facility
IP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX203439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.33
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
|
|
COAGULATION FACTOR IX (RECOMB) 3,000 UNIT INTRAVENOUS SOLUTION [203439]
|
Facility
OP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX203439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.52
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: Dignity Health Senior |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Humana Medicare |
$1.75
|
| Rate for Payer: IEHP Medicare Advantage |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$1.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.93
|
| Rate for Payer: TriValley Medical Group Senior |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.75
|
|
|
COAGULATION FACTOR IX (RECOMB) 500 UNIT INTRAVENOUS SOLUTION [203436]
|
Facility
IP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX203436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.33
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
|
|
COAGULATION FACTOR IX (RECOMB) 500 UNIT INTRAVENOUS SOLUTION [203436]
|
Facility
OP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX203436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.52
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: Dignity Health Senior |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Humana Medicare |
$1.75
|
| Rate for Payer: IEHP Medicare Advantage |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$1.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.93
|
| Rate for Payer: TriValley Medical Group Senior |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.75
|
|
|
COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION [92853]
|
Facility
OP
|
$3.08
|
|
|
Service Code
|
CPT J7189
|
| Hospital Charge Code |
ERX92853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$5.96 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.77
|
| Rate for Payer: Blue Shield of California Commercial |
$2.53
|
| Rate for Payer: Blue Shield of California EPN |
$2.53
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.67
|
| Rate for Payer: Dignity Health Senior |
$2.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.97
|
| Rate for Payer: EPIC Health Plan Medicare |
$2.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Senior |
$1.43
|
| Rate for Payer: Humana Medicare |
$2.43
|
| Rate for Payer: IEHP Medicare Advantage |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.06
|
| Rate for Payer: Multiplan Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.67
|
| Rate for Payer: TriValley Medical Group Senior |
$2.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Vantage Medical Group Senior |
$2.43
|
|
|
COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION [92853]
|
Facility
IP
|
$3.08
|
|
|
Service Code
|
CPT J7189
|
| Hospital Charge Code |
ERX92853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.12
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.09
|
| Rate for Payer: Heritage Provider Network Senior |
$2.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.03
|
|
|
COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION [92854]
|
Facility
OP
|
$3.08
|
|
|
Service Code
|
CPT J7189
|
| Hospital Charge Code |
ERX92854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$5.96 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.77
|
| Rate for Payer: Blue Shield of California Commercial |
$2.53
|
| Rate for Payer: Blue Shield of California EPN |
$2.53
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.67
|
| Rate for Payer: Dignity Health Senior |
$2.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.97
|
| Rate for Payer: EPIC Health Plan Medicare |
$2.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Senior |
$1.43
|
| Rate for Payer: Humana Medicare |
$2.43
|
| Rate for Payer: IEHP Medicare Advantage |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.06
|
| Rate for Payer: Multiplan Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.67
|
| Rate for Payer: TriValley Medical Group Senior |
$2.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Vantage Medical Group Senior |
$2.43
|
|
