|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 50268-127-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION [29396]
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS J0583
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$71.40 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$57.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$44.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$57.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$91.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$59.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$63.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$81.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.78
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$49.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$91.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$91.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.40
|
| Rate for Payer: Dignity Health Senior |
$91.80
|
| Rate for Payer: Dignity Health Senior |
$71.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.00
|
| Rate for Payer: Heritage Provider Network Senior |
$50.00
|
| Rate for Payer: Heritage Provider Network Senior |
$38.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$40.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$51.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$58.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$75.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$75.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$58.80
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$81.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$33.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.20
|
| Rate for Payer: TriValley Medical Group Senior |
$43.20
|
| Rate for Payer: TriValley Medical Group Senior |
$33.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$35.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$91.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$91.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$91.80
|
| Rate for Payer: Vantage Medical Group Senior |
$71.40
|
|
|
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION [29396]
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
HCPCS J0583
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$49.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.00
|
| Rate for Payer: Heritage Provider Network Senior |
$50.00
|
| Rate for Payer: Heritage Provider Network Senior |
$38.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$81.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$35.76
|
|
|
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION [9289]
|
Facility
|
IP
|
$39.74
|
|
|
Service Code
|
HCPCS J9040
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.19 |
| Max. Negotiated Rate |
$29.80 |
| Rate for Payer: Adventist Health Commercial |
$7.95
|
| Rate for Payer: Adventist Health Commercial |
$12.11
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cash Price |
$21.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.40
|
| Rate for Payer: Heritage Provider Network Senior |
$18.40
|
| Rate for Payer: Heritage Provider Network Senior |
$28.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.94
|
| Rate for Payer: Multiplan Commercial |
$45.41
|
| Rate for Payer: Multiplan Commercial |
$29.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.16
|
|
|
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION [9289]
|
Facility
|
OP
|
$60.55
|
|
|
Service Code
|
HCPCS J9040
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.96 |
| Max. Negotiated Rate |
$101.55 |
| Rate for Payer: Adventist Health Commercial |
$12.11
|
| Rate for Payer: Adventist Health Commercial |
$7.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$21.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$32.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$29.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.55
|
| Rate for Payer: Blue Shield of California Commercial |
$39.99
|
| Rate for Payer: Blue Shield of California Commercial |
$39.99
|
| Rate for Payer: Blue Shield of California EPN |
$39.99
|
| Rate for Payer: Blue Shield of California EPN |
$39.99
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cash Price |
$21.86
|
| Rate for Payer: Cash Price |
$21.86
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.47
|
| Rate for Payer: Dignity Health Senior |
$33.78
|
| Rate for Payer: Dignity Health Senior |
$51.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.40
|
| Rate for Payer: Heritage Provider Network Senior |
$18.40
|
| Rate for Payer: Heritage Provider Network Senior |
$28.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$42.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$27.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$27.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$42.38
|
| Rate for Payer: Multiplan Commercial |
$45.41
|
| Rate for Payer: Multiplan Commercial |
$29.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.90
|
| Rate for Payer: TriValley Medical Group Senior |
$15.90
|
| Rate for Payer: TriValley Medical Group Senior |
$24.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.47
|
| Rate for Payer: Vantage Medical Group Senior |
$33.78
|
| Rate for Payer: Vantage Medical Group Senior |
$51.47
|
|
|
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION [17012]
|
Facility
|
IP
|
$112.34
|
|
|
Service Code
|
HCPCS J9040
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.33 |
| Max. Negotiated Rate |
$84.25 |
| Rate for Payer: Adventist Health Commercial |
$22.47
|
| Rate for Payer: Adventist Health Commercial |
$16.01
|
| Rate for Payer: Cash Price |
$44.02
|
| Rate for Payer: Cash Price |
$61.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.01
|
| Rate for Payer: Heritage Provider Network Senior |
$52.01
|
| Rate for Payer: Heritage Provider Network Senior |
$37.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.09
|
| Rate for Payer: Multiplan Commercial |
$60.02
|
| Rate for Payer: Multiplan Commercial |
$84.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$28.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.20
|
|
|
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION [17012]
|
Facility
|
OP
|
$80.03
|
|
|
Service Code
|
HCPCS J9040
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.49 |
| Max. Negotiated Rate |
$101.55 |
| Rate for Payer: Adventist Health Commercial |
$16.01
|
| Rate for Payer: Adventist Health Commercial |
$22.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$60.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$42.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$68.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$44.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$60.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.55
|
| Rate for Payer: Blue Shield of California Commercial |
$39.99
|
| Rate for Payer: Blue Shield of California Commercial |
$39.99
|
| Rate for Payer: Blue Shield of California EPN |
$39.99
|
| Rate for Payer: Blue Shield of California EPN |
$39.99
|
| Rate for Payer: Cash Price |
$44.02
|
| Rate for Payer: Cash Price |
$61.79
|
| Rate for Payer: Cash Price |
$61.79
|
| Rate for Payer: Cash Price |
$44.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.03
|
| Rate for Payer: Dignity Health Senior |
$95.49
|
| Rate for Payer: Dignity Health Senior |
$68.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.01
|
| Rate for Payer: Heritage Provider Network Senior |
$52.01
|
| Rate for Payer: Heritage Provider Network Senior |
$37.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$53.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$56.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$56.02
|
| Rate for Payer: Multiplan Commercial |
$60.02
|
| Rate for Payer: Multiplan Commercial |
$84.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$32.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$44.94
|
| Rate for Payer: TriValley Medical Group Senior |
$44.94
|
| Rate for Payer: TriValley Medical Group Senior |
$32.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$28.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$68.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.03
|
| Rate for Payer: Vantage Medical Group Senior |
$95.49
|
| Rate for Payer: Vantage Medical Group Senior |
$68.03
|
|
|
BORIC ACID (BULK) POWDER [1131]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 3877900649
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.80
|
| Rate for Payer: Dignity Health Senior |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
BORIC ACID (BULK) POWDER [1131]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 3877900649
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
|
|
BORIC ACID (BULK) POWDER [1131]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 3877900648
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
|
|
BORIC ACID (BULK) POWDER [1131]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 3877900648
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.80
|
| Rate for Payer: Dignity Health Senior |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
HCPCS J9041
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Adventist Health Commercial |
$60.00
|
| Rate for Payer: Adventist Health Commercial |
$10.08
|
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$128.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.94
|
| Rate for Payer: Aetna of CA Gatekeeper |
$160.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$206.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$255.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$165.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$225.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$180.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.37
|
| Rate for Payer: Blue Shield of California Commercial |
$3.74
|
| Rate for Payer: Blue Shield of California Commercial |
$3.74
|
| Rate for Payer: Blue Shield of California Commercial |
$3.74
|
| Rate for Payer: Blue Shield of California EPN |
$3.74
|
| Rate for Payer: Blue Shield of California EPN |
$3.74
|
| Rate for Payer: Blue Shield of California EPN |
$3.74
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$27.72
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$27.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$138.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$255.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$255.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.84
|
| Rate for Payer: Dignity Health Senior |
$42.84
|
| Rate for Payer: Dignity Health Senior |
$204.00
|
| Rate for Payer: Dignity Health Senior |
$255.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$192.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$153.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$138.90
|
| Rate for Payer: Heritage Provider Network Senior |
$23.34
|
| Rate for Payer: Heritage Provider Network Senior |
$111.12
|
| Rate for Payer: Heritage Provider Network Senior |
$138.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$114.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$143.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$210.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$35.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$168.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$35.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$210.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$168.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$225.00
|
| Rate for Payer: Multiplan Commercial |
$37.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$20.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$120.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$96.00
|
| Rate for Payer: TriValley Medical Group Senior |
$96.00
|
| Rate for Payer: TriValley Medical Group Senior |
$20.16
|
| Rate for Payer: TriValley Medical Group Senior |
$120.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$108.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$86.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$99.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$79.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$255.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$255.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.84
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$42.84
|
| Rate for Payer: Vantage Medical Group Senior |
$255.00
|
|
|
BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
HCPCS J9041
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.30 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Adventist Health Commercial |
$60.00
|
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Adventist Health Commercial |
$10.08
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cash Price |
$27.72
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$138.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$129.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$138.90
|
| Rate for Payer: Heritage Provider Network Senior |
$138.90
|
| Rate for Payer: Heritage Provider Network Senior |
$111.12
|
| Rate for Payer: Heritage Provider Network Senior |
$23.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.60
|
| Rate for Payer: Multiplan Commercial |
$37.80
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$86.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$108.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$79.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$99.33
|
|
|
BOSENTAN 125 MG TABLET [31876]
|
Facility
|
IP
|
$17.45
|
|
|
Service Code
|
NDC 68382-447-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$13.09 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.81
|
| Rate for Payer: Heritage Provider Network Senior |
$11.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.36
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
|
|
BOSENTAN 125 MG TABLET [31876]
|
Facility
|
OP
|
$17.45
|
|
|
Service Code
|
NDC 68382-447-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.09
|
| Rate for Payer: Blue Shield of California Commercial |
$10.64
|
| Rate for Payer: Blue Shield of California EPN |
$8.52
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.83
|
| Rate for Payer: Dignity Health Senior |
$14.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.80
|
| Rate for Payer: Heritage Provider Network Senior |
$10.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.21
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.98
|
| Rate for Payer: TriValley Medical Group Senior |
$6.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.83
|
|
|
BOSENTAN 31.25 MG 1/2 TABLET [4081538]
|
Facility
|
IP
|
$17.45
|
|
|
Service Code
|
NDC 68382-446-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$13.09 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.81
|
| Rate for Payer: Heritage Provider Network Senior |
$11.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.36
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
|
|
BOSENTAN 31.25 MG 1/2 TABLET [4081538]
|
Facility
|
OP
|
$17.45
|
|
|
Service Code
|
NDC 68382-446-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.09
|
| Rate for Payer: Blue Shield of California Commercial |
$10.64
|
| Rate for Payer: Blue Shield of California EPN |
$8.52
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.83
|
| Rate for Payer: Dignity Health Senior |
$14.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.80
|
| Rate for Payer: Heritage Provider Network Senior |
$10.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.21
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.98
|
| Rate for Payer: TriValley Medical Group Senior |
$6.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.83
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$268.28
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.56 |
| Max. Negotiated Rate |
$228.04 |
| Rate for Payer: Adventist Health Commercial |
$53.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$143.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$184.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$228.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$201.21
|
| Rate for Payer: Blue Shield of California Commercial |
$163.65
|
| Rate for Payer: Blue Shield of California EPN |
$130.92
|
| Rate for Payer: Cash Price |
$147.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$174.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.04
|
| Rate for Payer: Dignity Health Senior |
$228.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$166.07
|
| Rate for Payer: Heritage Provider Network Senior |
$166.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$127.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$187.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$187.80
|
| Rate for Payer: Multiplan Commercial |
$201.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$107.31
|
| Rate for Payer: TriValley Medical Group Senior |
$107.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$134.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$134.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$228.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.04
|
| Rate for Payer: Vantage Medical Group Senior |
$228.04
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$268.28
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.56 |
| Max. Negotiated Rate |
$201.21 |
| Rate for Payer: Adventist Health Commercial |
$53.66
|
| Rate for Payer: Cash Price |
$147.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$144.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$181.63
|
| Rate for Payer: Heritage Provider Network Senior |
$181.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.07
|
| Rate for Payer: Multiplan Commercial |
$201.21
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$17.45
|
|
|
Service Code
|
NDC 68382-446-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.09
|
| Rate for Payer: Blue Shield of California Commercial |
$10.64
|
| Rate for Payer: Blue Shield of California EPN |
$8.52
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.83
|
| Rate for Payer: Dignity Health Senior |
$14.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.80
|
| Rate for Payer: Heritage Provider Network Senior |
$10.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.21
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.98
|
| Rate for Payer: TriValley Medical Group Senior |
$6.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.83
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$268.28
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.56 |
| Max. Negotiated Rate |
$201.21 |
| Rate for Payer: Adventist Health Commercial |
$53.66
|
| Rate for Payer: Cash Price |
$147.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$144.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$181.63
|
| Rate for Payer: Heritage Provider Network Senior |
$181.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.07
|
| Rate for Payer: Multiplan Commercial |
$201.21
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$17.45
|
|
|
Service Code
|
NDC 68382-446-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$13.09 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.81
|
| Rate for Payer: Heritage Provider Network Senior |
$11.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.36
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$268.28
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.56 |
| Max. Negotiated Rate |
$228.04 |
| Rate for Payer: Adventist Health Commercial |
$53.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$143.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$184.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$228.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$201.21
|
| Rate for Payer: Blue Shield of California Commercial |
$163.65
|
| Rate for Payer: Blue Shield of California EPN |
$130.92
|
| Rate for Payer: Cash Price |
$147.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$174.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.04
|
| Rate for Payer: Dignity Health Senior |
$228.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$166.07
|
| Rate for Payer: Heritage Provider Network Senior |
$166.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$127.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$187.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$187.80
|
| Rate for Payer: Multiplan Commercial |
$201.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$107.31
|
| Rate for Payer: TriValley Medical Group Senior |
$107.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$134.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$134.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$228.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.04
|
| Rate for Payer: Vantage Medical Group Senior |
$228.04
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
IP
|
$268.28
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.56 |
| Max. Negotiated Rate |
$201.21 |
| Rate for Payer: Adventist Health Commercial |
$53.66
|
| Rate for Payer: Cash Price |
$147.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$144.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$181.63
|
| Rate for Payer: Heritage Provider Network Senior |
$181.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.07
|
| Rate for Payer: Multiplan Commercial |
$201.21
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
OP
|
$268.28
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.56 |
| Max. Negotiated Rate |
$228.04 |
| Rate for Payer: Adventist Health Commercial |
$53.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$143.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$184.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$228.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$201.21
|
| Rate for Payer: Blue Shield of California Commercial |
$163.65
|
| Rate for Payer: Blue Shield of California EPN |
$130.92
|
| Rate for Payer: Cash Price |
$147.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$174.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.04
|
| Rate for Payer: Dignity Health Senior |
$228.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$166.07
|
| Rate for Payer: Heritage Provider Network Senior |
$166.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$127.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$187.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$187.80
|
| Rate for Payer: Multiplan Commercial |
$201.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$107.31
|
| Rate for Payer: TriValley Medical Group Senior |
$107.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$134.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$134.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$228.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.04
|
| Rate for Payer: Vantage Medical Group Senior |
$228.04
|
|
