|
ABACAVIR 600 MG-LAMIVUDINE 300 MG TABLET [39301]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 6909736202
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.58
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
|
|
ABATACEPT (WITH MALTOSE) 250 MG INTRAVENOUS SOLUTION [70287]
|
Facility
|
IP
|
$1,925.10
|
|
|
Service Code
|
HCPCS J0129
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$348.44 |
| Max. Negotiated Rate |
$1,443.83 |
| Rate for Payer: Adventist Health Commercial |
$385.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,239.76
|
| Rate for Payer: Cash Price |
$866.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$885.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,039.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$891.32
|
| Rate for Payer: Heritage Provider Network Senior |
$891.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$348.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$481.27
|
| Rate for Payer: Multiplan Commercial |
$1,443.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$695.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$637.40
|
|
|
ABATACEPT (WITH MALTOSE) 250 MG INTRAVENOUS SOLUTION [70287]
|
Facility
|
OP
|
$1,925.10
|
|
|
Service Code
|
HCPCS J0129
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.57 |
| Max. Negotiated Rate |
$1,443.83 |
| Rate for Payer: Adventist Health Commercial |
$385.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,189.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$57.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$50.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$50.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$45.57
|
| Rate for Payer: Blue Shield of California Commercial |
$59.67
|
| Rate for Payer: Blue Shield of California EPN |
$59.67
|
| Rate for Payer: Cash Price |
$866.30
|
| Rate for Payer: Cash Price |
$866.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$885.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$50.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,232.06
|
| Rate for Payer: EPIC Health Plan Medicare |
$45.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$891.32
|
| Rate for Payer: Heritage Provider Network Senior |
$891.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$45.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$918.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$348.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$52.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$481.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$61.45
|
| Rate for Payer: Multiplan Commercial |
$1,443.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$770.04
|
| Rate for Payer: TriValley Medical Group Senior |
$770.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$695.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$637.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$57.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.45
|
| Rate for Payer: Vantage Medical Group Senior |
$50.45
|
|
|
ABEMACICLIB 100 MG TABLET [219901]
|
Facility
|
IP
|
$370.93
|
|
|
Service Code
|
NDC 0002481554
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.14 |
| Max. Negotiated Rate |
$278.20 |
| Rate for Payer: Adventist Health Commercial |
$74.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$238.88
|
| Rate for Payer: Cash Price |
$166.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$200.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$251.12
|
| Rate for Payer: Heritage Provider Network Senior |
$251.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$67.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$92.73
|
| Rate for Payer: Multiplan Commercial |
$278.20
|
|
|
ABEMACICLIB 100 MG TABLET [219901]
|
Facility
|
OP
|
$370.93
|
|
|
Service Code
|
NDC 0002481554
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.14 |
| Max. Negotiated Rate |
$315.29 |
| Rate for Payer: Adventist Health Commercial |
$74.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$315.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$204.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$278.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$185.54
|
| Rate for Payer: Blue Shield of California Commercial |
$226.27
|
| Rate for Payer: Blue Shield of California EPN |
$181.01
|
| Rate for Payer: Cash Price |
$166.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$241.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$315.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$315.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$315.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$237.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$229.61
|
| Rate for Payer: Heritage Provider Network Senior |
$229.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$176.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$67.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$92.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$259.65
|
| Rate for Payer: Multiplan Commercial |
$278.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$148.37
|
| Rate for Payer: TriValley Medical Group Senior |
$148.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$185.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$185.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$315.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$315.29
|
| Rate for Payer: Vantage Medical Group Senior |
$315.29
|
|
|
ABEMACICLIB 150 MG TABLET [219900]
|
Facility
|
IP
|
$370.93
|
|
|
Service Code
|
NDC 0002533754
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.14 |
| Max. Negotiated Rate |
$278.20 |
| Rate for Payer: Adventist Health Commercial |
$74.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$238.88
|
| Rate for Payer: Cash Price |
$166.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$200.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$251.12
|
| Rate for Payer: Heritage Provider Network Senior |
$251.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$67.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$92.73
|
| Rate for Payer: Multiplan Commercial |
$278.20
|
|
|
ABEMACICLIB 150 MG TABLET [219900]
|
Facility
|
OP
|
$370.93
|
|
|
Service Code
|
NDC 0002533754
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.14 |
| Max. Negotiated Rate |
$315.29 |
| Rate for Payer: Adventist Health Commercial |
$74.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$315.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$204.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$278.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$185.54
|
| Rate for Payer: Blue Shield of California Commercial |
$226.27
|
| Rate for Payer: Blue Shield of California EPN |
$181.01
|
| Rate for Payer: Cash Price |
$166.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$241.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$315.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$315.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$315.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$237.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$229.61
|
| Rate for Payer: Heritage Provider Network Senior |
$229.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$176.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$67.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$92.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$259.65
|
| Rate for Payer: Multiplan Commercial |
$278.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$148.37
|
| Rate for Payer: TriValley Medical Group Senior |
$148.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$185.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$185.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$315.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$315.29
|
| Rate for Payer: Vantage Medical Group Senior |
$315.29
|
|
|
ABEMACICLIB 200 MG TABLET [219899]
|
Facility
|
IP
|
$370.93
|
|
|
Service Code
|
NDC 0002621654
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.14 |
| Max. Negotiated Rate |
$278.20 |
| Rate for Payer: Adventist Health Commercial |
$74.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$238.88
|
| Rate for Payer: Cash Price |
$166.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$200.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$251.12
|
| Rate for Payer: Heritage Provider Network Senior |
$251.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$67.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$92.73
|
| Rate for Payer: Multiplan Commercial |
$278.20
|
|
|
ABEMACICLIB 200 MG TABLET [219899]
|
Facility
|
OP
|
$370.93
|
|
|
Service Code
|
NDC 0002621654
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.14 |
| Max. Negotiated Rate |
$315.29 |
| Rate for Payer: Adventist Health Commercial |
$74.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$315.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$204.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$278.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$185.54
|
| Rate for Payer: Blue Shield of California Commercial |
$226.27
|
| Rate for Payer: Blue Shield of California EPN |
$181.01
|
| Rate for Payer: Cash Price |
$166.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$241.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$315.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$315.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$315.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$237.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$229.61
|
| Rate for Payer: Heritage Provider Network Senior |
$229.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$176.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$67.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$92.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$259.65
|
| Rate for Payer: Multiplan Commercial |
$278.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$148.37
|
| Rate for Payer: TriValley Medical Group Senior |
$148.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$185.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$185.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$315.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$315.29
|
| Rate for Payer: Vantage Medical Group Senior |
$315.29
|
|
|
ABEMACICLIB 50 MG TABLET [219902]
|
Facility
|
OP
|
$370.93
|
|
|
Service Code
|
NDC 0002448354
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.14 |
| Max. Negotiated Rate |
$315.29 |
| Rate for Payer: Adventist Health Commercial |
$74.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$315.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$204.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$278.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$185.54
|
| Rate for Payer: Blue Shield of California Commercial |
$226.27
|
| Rate for Payer: Blue Shield of California EPN |
$181.01
|
| Rate for Payer: Cash Price |
$166.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$241.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$315.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$315.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$315.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$237.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$229.61
|
| Rate for Payer: Heritage Provider Network Senior |
$229.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$176.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$67.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$92.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$259.65
|
| Rate for Payer: Multiplan Commercial |
$278.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$148.37
|
| Rate for Payer: TriValley Medical Group Senior |
$148.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$185.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$185.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$315.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$315.29
|
| Rate for Payer: Vantage Medical Group Senior |
$315.29
|
|
|
ABEMACICLIB 50 MG TABLET [219902]
|
Facility
|
IP
|
$370.93
|
|
|
Service Code
|
NDC 0002448354
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.14 |
| Max. Negotiated Rate |
$278.20 |
| Rate for Payer: Adventist Health Commercial |
$74.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$238.88
|
| Rate for Payer: Cash Price |
$166.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$200.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$251.12
|
| Rate for Payer: Heritage Provider Network Senior |
$251.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$67.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$92.73
|
| Rate for Payer: Multiplan Commercial |
$278.20
|
|
|
ABIRATERONE 250 MG TABLET [109776]
|
Facility
|
IP
|
$125.67
|
|
|
Service Code
|
NDC 5789415012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$94.25 |
| Rate for Payer: Adventist Health Commercial |
$25.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.93
|
| Rate for Payer: Cash Price |
$56.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.08
|
| Rate for Payer: Heritage Provider Network Senior |
$85.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.42
|
| Rate for Payer: Multiplan Commercial |
$94.25
|
|
|
ABIRATERONE 250 MG TABLET [109776]
|
Facility
|
OP
|
$125.67
|
|
|
Service Code
|
NDC 5789415012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$106.82 |
| Rate for Payer: Adventist Health Commercial |
$25.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$106.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$94.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$62.86
|
| Rate for Payer: Blue Shield of California Commercial |
$76.66
|
| Rate for Payer: Blue Shield of California EPN |
$61.33
|
| Rate for Payer: Cash Price |
$56.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$81.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$106.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$106.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$106.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$77.79
|
| Rate for Payer: Heritage Provider Network Senior |
$77.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$59.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$87.97
|
| Rate for Payer: Multiplan Commercial |
$94.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$50.27
|
| Rate for Payer: TriValley Medical Group Senior |
$50.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$62.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$62.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$106.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$106.82
|
| Rate for Payer: Vantage Medical Group Senior |
$106.82
|
|
|
ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 30802
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,995.60 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,993.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,195.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,995.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,993.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,195.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,995.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,995.60
|
| Rate for Payer: Heritage Provider Network Senior |
$2,454.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,995.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,791.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,294.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,674.10
|
| Rate for Payer: Multiplan WC |
$2,998.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,195.16
|
| Rate for Payer: TriValley Medical Group Senior |
$2,195.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,993.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,195.16
|
| Rate for Payer: Vantage Medical Group Senior |
$1,995.60
|
|
|
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION [106761]
|
Facility
|
IP
|
$634.20
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.79 |
| Max. Negotiated Rate |
$475.65 |
| Rate for Payer: Adventist Health Commercial |
$126.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$408.42
|
| Rate for Payer: Cash Price |
$285.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$291.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$342.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$293.63
|
| Rate for Payer: Heritage Provider Network Senior |
$293.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$114.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$158.55
|
| Rate for Payer: Multiplan Commercial |
$475.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$229.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$209.98
|
|
|
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION [106761]
|
Facility
|
OP
|
$634.20
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.76 |
| Max. Negotiated Rate |
$475.65 |
| Rate for Payer: Adventist Health Commercial |
$126.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$391.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.28
|
| Rate for Payer: Blue Shield of California Commercial |
$8.76
|
| Rate for Payer: Blue Shield of California EPN |
$8.76
|
| Rate for Payer: Cash Price |
$285.39
|
| Rate for Payer: Cash Price |
$285.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$291.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$405.89
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$293.63
|
| Rate for Payer: Heritage Provider Network Senior |
$293.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$302.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$114.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$158.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$475.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$253.68
|
| Rate for Payer: TriValley Medical Group Senior |
$253.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$229.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$209.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.85
|
| Rate for Payer: Vantage Medical Group Senior |
$9.85
|
|
|
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION [99465]
|
Facility
|
OP
|
$1,056.60
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.76 |
| Max. Negotiated Rate |
$792.45 |
| Rate for Payer: Adventist Health Commercial |
$211.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$652.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.28
|
| Rate for Payer: Blue Shield of California Commercial |
$8.76
|
| Rate for Payer: Blue Shield of California EPN |
$8.76
|
| Rate for Payer: Cash Price |
$475.47
|
| Rate for Payer: Cash Price |
$475.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$486.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$676.22
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$489.21
|
| Rate for Payer: Heritage Provider Network Senior |
$489.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$504.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$191.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$792.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$422.64
|
| Rate for Payer: TriValley Medical Group Senior |
$422.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$381.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$349.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.85
|
| Rate for Payer: Vantage Medical Group Senior |
$9.85
|
|
|
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION [99465]
|
Facility
|
IP
|
$1,056.60
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$191.24 |
| Max. Negotiated Rate |
$792.45 |
| Rate for Payer: Adventist Health Commercial |
$211.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$680.45
|
| Rate for Payer: Cash Price |
$475.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$486.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$570.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$489.21
|
| Rate for Payer: Heritage Provider Network Senior |
$489.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$191.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.15
|
| Rate for Payer: Multiplan Commercial |
$792.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$381.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$349.84
|
|
|
ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$16,098.52
|
|
|
Service Code
|
MSDRG 770
|
| Min. Negotiated Rate |
$12,013.82 |
| Max. Negotiated Rate |
$16,098.52 |
| Rate for Payer: EPIC Health Plan Medicare |
$12,013.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12,013.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,815.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16,098.52
|
|
|
ABORTION WITHOUT D&C
|
Facility
|
IP
|
$13,620.15
|
|
|
Service Code
|
MSDRG 779
|
| Min. Negotiated Rate |
$10,164.29 |
| Max. Negotiated Rate |
$13,620.15 |
| Rate for Payer: EPIC Health Plan Medicare |
$10,164.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10,164.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11,688.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13,620.15
|
|
|
ACAMPROSATE 333 MG TABLET,DELAYED RELEASE [39720]
|
Facility
|
OP
|
$0.99
|
|
|
Service Code
|
NDC 6945235325
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: Vantage Medical Group Senior |
$0.84
|
|
|
ACAMPROSATE 333 MG TABLET,DELAYED RELEASE [39720]
|
Facility
|
OP
|
$2.84
|
|
|
Service Code
|
NDC 0904721304
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.76
|
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1.73
|
| Rate for Payer: Blue Shield of California EPN |
$1.39
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.76
|
| Rate for Payer: Heritage Provider Network Senior |
$1.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.99
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.14
|
| Rate for Payer: TriValley Medical Group Senior |
$1.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.41
|
| Rate for Payer: Vantage Medical Group Senior |
$2.41
|
|
|
ACAMPROSATE 333 MG TABLET,DELAYED RELEASE [39720]
|
Facility
|
OP
|
$1.04
|
|
|
Service Code
|
NDC 5107924106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Senior |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Vantage Medical Group Senior |
$0.88
|
|
|
ACAMPROSATE 333 MG TABLET,DELAYED RELEASE [39720]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 0378633380
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Vantage Medical Group Senior |
$0.92
|
|
|
ACAMPROSATE 333 MG TABLET,DELAYED RELEASE [39720]
|
Facility
|
IP
|
$1.04
|
|
|
Service Code
|
NDC 5107924106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.67
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
|
