|
ARIPIPRAZOLE 1 MG/ML ORAL SOLUTION [40446]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 66689-735-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
ARIPIPRAZOLE 1 MG/ML ORAL SOLUTION [40446]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 72888-100-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.58
|
| Rate for Payer: Dignity Health Senior |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Senior |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Vantage Medical Group Senior |
$0.58
|
|
|
ARIPIPRAZOLE 2 MG TABLET [70306]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 62332-097-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
ARIPIPRAZOLE 2 MG TABLET [70306]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 62332-097-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
ARIPIPRAZOLE 2 MG TABLET [70306]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 67877-430-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
ARIPIPRAZOLE 2 MG TABLET [70306]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 67877-430-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
ARIPIPRAZOLE 5 MG TABLET [36438]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 62332-098-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
ARIPIPRAZOLE 5 MG TABLET [36438]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 50268-088-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
ARIPIPRAZOLE 5 MG TABLET [36438]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 50268-088-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Senior |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
ARIPIPRAZOLE 5 MG TABLET [36438]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 62332-098-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
ARIPIPRAZOLE 5 MG TABLET [36438]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 50268-088-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Senior |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
ARIPIPRAZOLE 5 MG TABLET [36438]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 50268-088-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION [29071]
|
Facility
|
IP
|
$45.49
|
|
|
Service Code
|
HCPCS J9017
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.23 |
| Max. Negotiated Rate |
$34.12 |
| Rate for Payer: Adventist Health Commercial |
$9.10
|
| Rate for Payer: Adventist Health Commercial |
$3.60
|
| Rate for Payer: Cash Price |
$25.02
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.06
|
| Rate for Payer: Heritage Provider Network Senior |
$21.06
|
| Rate for Payer: Heritage Provider Network Senior |
$8.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$34.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.96
|
|
|
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION [29071]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J9017
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$85.81 |
| Rate for Payer: Adventist Health Commercial |
$3.60
|
| Rate for Payer: Adventist Health Commercial |
$9.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$85.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$85.81
|
| Rate for Payer: Blue Shield of California Commercial |
$34.36
|
| Rate for Payer: Blue Shield of California Commercial |
$34.36
|
| Rate for Payer: Blue Shield of California EPN |
$34.36
|
| Rate for Payer: Blue Shield of California EPN |
$34.36
|
| Rate for Payer: Cash Price |
$25.02
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cash Price |
$25.02
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.44
|
| Rate for Payer: Dignity Health Senior |
$6.44
|
| Rate for Payer: Dignity Health Senior |
$6.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.11
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.86
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.06
|
| Rate for Payer: Heritage Provider Network Senior |
$8.33
|
| Rate for Payer: Heritage Provider Network Senior |
$21.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.38
|
| Rate for Payer: Multiplan Commercial |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$34.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.20
|
| Rate for Payer: TriValley Medical Group Senior |
$7.20
|
| Rate for Payer: TriValley Medical Group Senior |
$18.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.44
|
| Rate for Payer: Vantage Medical Group Senior |
$6.44
|
| Rate for Payer: Vantage Medical Group Senior |
$6.44
|
|
|
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION [220455]
|
Facility
|
IP
|
$255.26
|
|
|
Service Code
|
HCPCS J9017
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$191.44 |
| Rate for Payer: Adventist Health Commercial |
$51.05
|
| Rate for Payer: Cash Price |
$140.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$117.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$118.19
|
| Rate for Payer: Heritage Provider Network Senior |
$118.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.81
|
| Rate for Payer: Multiplan Commercial |
$191.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$92.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$84.52
|
|
|
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION [220455]
|
Facility
|
OP
|
$255.26
|
|
|
Service Code
|
HCPCS J9017
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.79 |
| Max. Negotiated Rate |
$191.44 |
| Rate for Payer: Adventist Health Commercial |
$51.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$136.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$175.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$85.81
|
| Rate for Payer: Blue Shield of California Commercial |
$34.36
|
| Rate for Payer: Blue Shield of California EPN |
$34.36
|
| Rate for Payer: Cash Price |
$140.39
|
| Rate for Payer: Cash Price |
$140.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$117.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.44
|
| Rate for Payer: Dignity Health Senior |
$6.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$163.37
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$118.19
|
| Rate for Payer: Heritage Provider Network Senior |
$118.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$121.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.38
|
| Rate for Payer: Multiplan Commercial |
$191.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$102.10
|
| Rate for Payer: TriValley Medical Group Senior |
$102.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$92.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$84.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.44
|
| Rate for Payer: Vantage Medical Group Senior |
$6.44
|
|
|
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET [96948]
|
Facility
|
OP
|
$6.74
|
|
|
Service Code
|
NDC 0078-0568-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$5.73 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.05
|
| Rate for Payer: Blue Shield of California Commercial |
$4.11
|
| Rate for Payer: Blue Shield of California EPN |
$3.29
|
| Rate for Payer: Cash Price |
$3.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.73
|
| Rate for Payer: Dignity Health Senior |
$5.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.17
|
| Rate for Payer: Heritage Provider Network Senior |
$4.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.72
|
| Rate for Payer: Multiplan Commercial |
$5.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Senior |
$2.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.73
|
| Rate for Payer: Vantage Medical Group Senior |
$5.73
|
|
|
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET [96948]
|
Facility
|
IP
|
$6.74
|
|
|
Service Code
|
NDC 0078-0568-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Cash Price |
$3.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.56
|
| Rate for Payer: Heritage Provider Network Senior |
$4.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.69
|
| Rate for Payer: Multiplan Commercial |
$5.05
|
|
|
ARTIFICIAL TEARS(DEXTRAN-HYPROMEL-GLYCERN) 0.1 %-0.3 %-0.2 % EYE DROPS [114932]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 0065-0426-36
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
ARTIFICIAL TEARS(DEXTRAN-HYPROMEL-GLYCERN) 0.1 %-0.3 %-0.2 % EYE DROPS [114932]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 0065-0426-36
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: Dignity Health Senior |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 57896-184-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| 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 |
$0.11
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 0023-0798-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 7430001067
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 7430001067
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 57896-181-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| 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 |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
