|
ACYCLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [8974]
|
Facility
|
IP
|
$5.40
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.79
|
|
|
ACYCLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [8974]
|
Facility
|
OP
|
$5.40
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.59
|
| Rate for Payer: Dignity Health Senior |
$4.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.78
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.16
|
| Rate for Payer: TriValley Medical Group Senior |
$2.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$4.59
|
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.78
|
| Rate for Payer: Dignity Health Senior |
$1.78
|
| Rate for Payer: Dignity Health Senior |
$1.15
|
| Rate for Payer: Dignity Health Senior |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$1.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Senior |
$0.54
|
| Rate for Payer: TriValley Medical Group Senior |
$0.84
|
| Rate for Payer: TriValley Medical Group Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.78
|
| Rate for Payer: Vantage Medical Group Senior |
$1.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1.78
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
|
|
ADAGRASIB 200 MG TABLET [236395]
|
Facility
|
OP
|
$150.62
|
|
|
Service Code
|
NDC 80739-812-18
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.26 |
| Max. Negotiated Rate |
$128.03 |
| Rate for Payer: Adventist Health Commercial |
$30.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$80.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$103.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$128.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$82.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$112.97
|
| Rate for Payer: Blue Shield of California Commercial |
$91.88
|
| Rate for Payer: Blue Shield of California EPN |
$73.50
|
| Rate for Payer: Cash Price |
$82.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$97.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$128.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$128.03
|
| Rate for Payer: Dignity Health Senior |
$128.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$93.23
|
| Rate for Payer: Heritage Provider Network Senior |
$93.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$71.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$105.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$105.43
|
| Rate for Payer: Multiplan Commercial |
$112.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$60.25
|
| Rate for Payer: TriValley Medical Group Senior |
$60.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$75.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$75.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$128.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$128.03
|
| Rate for Payer: Vantage Medical Group Senior |
$128.03
|
|
|
ADAGRASIB 200 MG TABLET [236395]
|
Facility
|
IP
|
$150.62
|
|
|
Service Code
|
NDC 80739-812-18
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.26 |
| Max. Negotiated Rate |
$112.97 |
| Rate for Payer: Adventist Health Commercial |
$30.12
|
| Rate for Payer: Cash Price |
$82.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$101.97
|
| Rate for Payer: Heritage Provider Network Senior |
$101.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.66
|
| Rate for Payer: Multiplan Commercial |
$112.97
|
|
|
ADAPALENE 0.1 % TOPICAL CREAM [21831]
|
Facility
|
OP
|
$6.03
|
|
|
Service Code
|
NDC 45802-453-84
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.52
|
| Rate for Payer: Blue Shield of California Commercial |
$3.68
|
| Rate for Payer: Blue Shield of California EPN |
$2.94
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Senior |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.73
|
| Rate for Payer: Heritage Provider Network Senior |
$3.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.22
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.41
|
| Rate for Payer: TriValley Medical Group Senior |
$2.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
ADAPALENE 0.1 % TOPICAL CREAM [21831]
|
Facility
|
IP
|
$6.03
|
|
|
Service Code
|
NDC 45802-453-84
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.08
|
| Rate for Payer: Heritage Provider Network Senior |
$4.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
|
|
ADENOSINE 300 MCG/ML KIT (NICU) IN NS [4080614]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
NDC 9994-0806-14
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.87
|
| Rate for Payer: Heritage Provider Network Senior |
$4.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
|
|
ADENOSINE 300 MCG/ML KIT (NICU) IN NS [4080614]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
NDC 9994-0806-14
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$6.12 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.40
|
| Rate for Payer: Blue Shield of California Commercial |
$4.39
|
| Rate for Payer: Blue Shield of California EPN |
$3.51
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.12
|
| Rate for Payer: Dignity Health Senior |
$6.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.46
|
| Rate for Payer: Heritage Provider Network Senior |
$4.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.04
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.12
|
| Rate for Payer: Vantage Medical Group Senior |
$6.12
|
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [39477]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$3.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$4.93
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.19
|
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [39477]
|
Facility
|
OP
|
$6.57
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$5.58 |
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.81
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.58
|
| Rate for Payer: Dignity Health Senior |
$3.06
|
| Rate for Payer: Dignity Health Senior |
$5.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$3.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.93
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Senior |
$1.44
|
| Rate for Payer: TriValley Medical Group Senior |
$2.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.58
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$5.58
|
|
|
ADENOSINE 6 MG/2 ML VIAL - CODE [4080560]
|
Facility
|
OP
|
$6.57
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$5.58 |
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.81
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.58
|
| Rate for Payer: Dignity Health Senior |
$5.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.04
|
| Rate for Payer: Heritage Provider Network Senior |
$3.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.63
|
| Rate for Payer: TriValley Medical Group Senior |
$2.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.58
|
| Rate for Payer: Vantage Medical Group Senior |
$5.58
|
|
|
ADENOSINE 6 MG/2 ML VIAL - CODE [4080560]
|
Facility
|
IP
|
$6.57
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$4.93 |
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.04
|
| Rate for Payer: Heritage Provider Network Senior |
$3.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$4.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.18
|
|
|
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [15330]
|
Facility
|
OP
|
$5.72
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.81
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.86
|
| Rate for Payer: Dignity Health Senior |
$4.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.65
|
| Rate for Payer: Heritage Provider Network Senior |
$2.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.00
|
| Rate for Payer: Multiplan Commercial |
$4.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.29
|
| Rate for Payer: TriValley Medical Group Senior |
$2.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.86
|
| Rate for Payer: Vantage Medical Group Senior |
$4.86
|
|
|
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [15330]
|
Facility
|
IP
|
$5.72
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.65
|
| Rate for Payer: Heritage Provider Network Senior |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.89
|
|
|
ADJUVANT AS01B (PF), COMPONENT VIAL 1 OF 2 INTRAMUSCULAR SUSPENSION [219987]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 58160-829-03
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ADJUVANT AS01B (PF), COMPONENT VIAL 1 OF 2 INTRAMUSCULAR SUSPENSION [219987]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 58160-829-03
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
AGAR (BULK) 100 % POWDER [40822641]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 9999-9226-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
AGAR (BULK) 100 % POWDER [40822641]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 9999-9226-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
ALBENDAZOLE 200 MG TABLET [8979]
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
NDC 31722-935-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.37
|
| Rate for Payer: Heritage Provider Network Senior |
$24.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
|
|
ALBENDAZOLE 200 MG TABLET [8979]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
NDC 31722-935-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$30.60 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.00
|
| Rate for Payer: Blue Shield of California Commercial |
$21.96
|
| Rate for Payer: Blue Shield of California EPN |
$17.57
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.60
|
| Rate for Payer: Dignity Health Senior |
$30.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.28
|
| Rate for Payer: Heritage Provider Network Senior |
$22.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.40
|
| Rate for Payer: TriValley Medical Group Senior |
$14.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.60
|
| Rate for Payer: Vantage Medical Group Senior |
$30.60
|
|
|
ALBENDAZOLE 200 MG TABLET [8979]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
NDC 43598-452-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.50
|
| Rate for Payer: Heritage Provider Network Senior |
$32.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
|
|
ALBENDAZOLE 200 MG TABLET [8979]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
NDC 43598-452-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$40.80 |
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.00
|
| Rate for Payer: Blue Shield of California Commercial |
$29.28
|
| Rate for Payer: Blue Shield of California EPN |
$23.42
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: Dignity Health Senior |
$40.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.71
|
| Rate for Payer: Heritage Provider Network Senior |
$29.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$33.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$33.60
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.20
|
| Rate for Payer: TriValley Medical Group Senior |
$19.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
|
|
ALBENDAZOLE 200 MG TABLET [8979]
|
Facility
|
OP
|
$35.85
|
|
|
Service Code
|
NDC 72205-051-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$30.47 |
| Rate for Payer: Adventist Health Commercial |
$7.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.89
|
| Rate for Payer: Blue Shield of California Commercial |
$21.87
|
| Rate for Payer: Blue Shield of California EPN |
$17.49
|
| Rate for Payer: Cash Price |
$19.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.47
|
| Rate for Payer: Dignity Health Senior |
$30.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.19
|
| Rate for Payer: Heritage Provider Network Senior |
$22.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.09
|
| Rate for Payer: Multiplan Commercial |
$26.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.34
|
| Rate for Payer: TriValley Medical Group Senior |
$14.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.47
|
| Rate for Payer: Vantage Medical Group Senior |
$30.47
|
|
