|
BALSAM PERU-CASTOR OIL TOPICAL OINTMENT IN PACKET [223630]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 5898078050
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.97
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
|
|
BANANA FLAKES-TRANSGALACTOOLIGOSACCHARIDE ORAL POWDER PACKET [37930]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 9468808470
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
BANANA FLAKES-TRANSGALACTOOLIGOSACCHARIDE ORAL POWDER PACKET [37930]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 9468808470
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.77
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
BARICITINIB 1 MG TABLET [225594]
|
Facility
|
IP
|
$114.02
|
|
|
Service Code
|
NDC 0002473230
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.64 |
| Max. Negotiated Rate |
$85.52 |
| Rate for Payer: Adventist Health Commercial |
$22.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$73.43
|
| Rate for Payer: Cash Price |
$51.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$77.19
|
| Rate for Payer: Heritage Provider Network Senior |
$77.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.50
|
| Rate for Payer: Multiplan Commercial |
$85.52
|
|
|
BARICITINIB 1 MG TABLET [225594]
|
Facility
|
OP
|
$114.02
|
|
|
Service Code
|
NDC 0002473230
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.64 |
| Max. Negotiated Rate |
$96.92 |
| Rate for Payer: Adventist Health Commercial |
$22.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$70.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$96.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$57.03
|
| Rate for Payer: Blue Shield of California Commercial |
$69.55
|
| Rate for Payer: Blue Shield of California EPN |
$55.64
|
| Rate for Payer: Cash Price |
$51.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$74.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$96.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$70.58
|
| Rate for Payer: Heritage Provider Network Senior |
$70.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$54.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$79.81
|
| Rate for Payer: Multiplan Commercial |
$85.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.61
|
| Rate for Payer: TriValley Medical Group Senior |
$45.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$57.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$57.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$96.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.92
|
| Rate for Payer: Vantage Medical Group Senior |
$96.92
|
|
|
BARICITINIB 2 MG TABLET [221907]
|
Facility
|
IP
|
$114.02
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.64 |
| Max. Negotiated Rate |
$85.52 |
| Rate for Payer: Adventist Health Commercial |
$22.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$73.43
|
| Rate for Payer: Cash Price |
$51.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$77.19
|
| Rate for Payer: Heritage Provider Network Senior |
$77.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.50
|
| Rate for Payer: Multiplan Commercial |
$85.52
|
|
|
BARICITINIB 2 MG TABLET [221907]
|
Facility
|
OP
|
$114.02
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.64 |
| Max. Negotiated Rate |
$96.92 |
| Rate for Payer: Adventist Health Commercial |
$22.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$70.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$96.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.52
|
| Rate for Payer: Blue Shield of California Commercial |
$69.55
|
| Rate for Payer: Blue Shield of California EPN |
$55.64
|
| Rate for Payer: Cash Price |
$51.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$74.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$96.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$70.58
|
| Rate for Payer: Heritage Provider Network Senior |
$70.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$54.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$79.81
|
| Rate for Payer: Multiplan Commercial |
$85.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.61
|
| Rate for Payer: TriValley Medical Group Senior |
$45.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$57.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$57.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$96.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.92
|
| Rate for Payer: Vantage Medical Group Senior |
$96.92
|
|
|
BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 3290916755
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 3290916755
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
BARIUM SULFATE 40 % (W/V), 29 % (W/W) (1,500 CPS) ORAL SUSPENSION [223877]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 3290912107
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
BARIUM SULFATE 40 % (W/V), 29 % (W/W) (1,500 CPS) ORAL SUSPENSION [223877]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 3290912107
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 3290975001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| 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 |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 3290975001
|
| 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 Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 3290975003
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 3290975003
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
BASILIXIMAB 20 MG INTRAVENOUS SOLUTION [23082]
|
Facility
|
IP
|
$5,692.03
|
|
|
Service Code
|
HCPCS J0480
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,030.26 |
| Max. Negotiated Rate |
$4,269.02 |
| Rate for Payer: Adventist Health Commercial |
$1,138.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,665.67
|
| Rate for Payer: Cash Price |
$2,561.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,618.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,073.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,635.41
|
| Rate for Payer: Heritage Provider Network Senior |
$2,635.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,030.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,423.01
|
| Rate for Payer: Multiplan Commercial |
$4,269.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,056.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,884.63
|
|
|
BASILIXIMAB 20 MG INTRAVENOUS SOLUTION [23082]
|
Facility
|
OP
|
$5,692.03
|
|
|
Service Code
|
HCPCS J0480
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,030.26 |
| Max. Negotiated Rate |
$6,572.77 |
| Rate for Payer: Adventist Health Commercial |
$1,138.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,517.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,131.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,395.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,395.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,407.82
|
| Rate for Payer: Blue Shield of California Commercial |
$4,559.16
|
| Rate for Payer: Blue Shield of California EPN |
$4,559.16
|
| Rate for Payer: Cash Price |
$2,561.41
|
| Rate for Payer: Cash Price |
$2,561.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,618.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,131.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,395.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5,395.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,642.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,905.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,635.41
|
| Rate for Payer: Heritage Provider Network Senior |
$2,635.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,905.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,715.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,030.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,640.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,423.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6,572.77
|
| Rate for Payer: Multiplan Commercial |
$4,269.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,276.81
|
| Rate for Payer: TriValley Medical Group Senior |
$2,276.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,056.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,884.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,131.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,395.56
|
| Rate for Payer: Vantage Medical Group Senior |
$5,395.56
|
|
|
BCG LIVE 50 MG INTRAVESICAL SUSPENSION [117851]
|
Facility
|
IP
|
$227.10
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.11 |
| Max. Negotiated Rate |
$170.32 |
| Rate for Payer: Adventist Health Commercial |
$45.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$146.25
|
| Rate for Payer: Cash Price |
$102.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$104.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$122.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$105.15
|
| Rate for Payer: Heritage Provider Network Senior |
$105.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$41.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.77
|
| Rate for Payer: Multiplan Commercial |
$170.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$82.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$75.19
|
|
|
BCG LIVE 50 MG INTRAVESICAL SUSPENSION [117851]
|
Facility
|
OP
|
$227.10
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$170.32 |
| Rate for Payer: Adventist Health Commercial |
$45.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$140.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.61
|
| Rate for Payer: Blue Shield of California Commercial |
$3.47
|
| Rate for Payer: Blue Shield of California EPN |
$3.47
|
| Rate for Payer: Cash Price |
$102.20
|
| Rate for Payer: Cash Price |
$102.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$104.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.34
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$105.15
|
| Rate for Payer: Heritage Provider Network Senior |
$105.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$108.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$41.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.53
|
| Rate for Payer: Multiplan Commercial |
$170.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$90.84
|
| Rate for Payer: TriValley Medical Group Senior |
$90.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$82.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$75.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.72
|
| Rate for Payer: Vantage Medical Group Senior |
$3.38
|
|
|
B-COMPLEX WITH VITAMIN C TABLET [807]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8068112600
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
B-COMPLEX WITH VITAMIN C TABLET [807]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 3160401338
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
B-COMPLEX WITH VITAMIN C TABLET [807]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 8068112600
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
B-COMPLEX WITH VITAMIN C TABLET [807]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 9999999807
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
B-COMPLEX WITH VITAMIN C TABLET [807]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 9999999807
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
B-COMPLEX WITH VITAMIN C TABLET [807]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 3160401338
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
