|
BEVACIZUMAB 25 MG/ML TOPICAL [4081093]
|
Facility
|
OP
|
$239.08
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.27 |
| Max. Negotiated Rate |
$179.31 |
| Rate for Payer: Adventist Health Commercial |
$47.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$147.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$112.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$82.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$74.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.90
|
| Rate for Payer: Blue Shield of California Commercial |
$81.29
|
| Rate for Payer: Blue Shield of California EPN |
$81.29
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$82.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$82.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$153.01
|
| Rate for Payer: EPIC Health Plan Medicare |
$74.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.69
|
| Rate for Payer: Heritage Provider Network Senior |
$110.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$74.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$114.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$43.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$86.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$100.26
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$95.63
|
| Rate for Payer: TriValley Medical Group Senior |
$95.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$86.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$79.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$93.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$82.30
|
| Rate for Payer: Vantage Medical Group Senior |
$82.30
|
|
|
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [225272]
|
Facility
|
IP
|
$209.32
|
|
|
Service Code
|
HCPCS Q5107
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.89 |
| Max. Negotiated Rate |
$156.99 |
| Rate for Payer: Adventist Health Commercial |
$41.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$134.80
|
| Rate for Payer: Cash Price |
$94.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$96.92
|
| Rate for Payer: Heritage Provider Network Senior |
$96.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$37.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.33
|
| Rate for Payer: Multiplan Commercial |
$156.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$75.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$69.31
|
|
|
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [225272]
|
Facility
|
OP
|
$209.32
|
|
|
Service Code
|
HCPCS Q5107
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.53 |
| Max. Negotiated Rate |
$182.26 |
| Rate for Payer: Adventist Health Commercial |
$41.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$129.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$182.26
|
| Rate for Payer: Blue Shield of California Commercial |
$71.17
|
| Rate for Payer: Blue Shield of California EPN |
$71.17
|
| Rate for Payer: Cash Price |
$94.19
|
| Rate for Payer: Cash Price |
$94.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$26.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.96
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$96.92
|
| Rate for Payer: Heritage Provider Network Senior |
$96.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$99.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$37.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.87
|
| Rate for Payer: Multiplan Commercial |
$156.99
|
| Rate for Payer: TriValley Medical Group Commercial |
$83.73
|
| Rate for Payer: TriValley Medical Group Senior |
$83.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$75.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$69.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.98
|
| Rate for Payer: Vantage Medical Group Senior |
$26.98
|
|
|
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION [216412]
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
HCPCS J0565
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.63 |
| Max. Negotiated Rate |
$92.07 |
| Rate for Payer: Adventist Health Commercial |
$22.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$70.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$49.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$43.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$43.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$92.07
|
| Rate for Payer: Blue Shield of California Commercial |
$38.76
|
| Rate for Payer: Blue Shield of California EPN |
$38.76
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$43.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.96
|
| Rate for Payer: EPIC Health Plan Medicare |
$39.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.78
|
| Rate for Payer: Heritage Provider Network Senior |
$52.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$39.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$54.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$45.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$53.37
|
| Rate for Payer: Multiplan Commercial |
$85.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.60
|
| Rate for Payer: TriValley Medical Group Senior |
$45.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$41.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$49.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.81
|
| Rate for Payer: Vantage Medical Group Senior |
$43.81
|
|
|
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION [216412]
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS J0565
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.63 |
| Max. Negotiated Rate |
$85.50 |
| Rate for Payer: Adventist Health Commercial |
$22.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$73.42
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.78
|
| Rate for Payer: Heritage Provider Network Senior |
$52.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.50
|
| Rate for Payer: Multiplan Commercial |
$85.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$41.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.75
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 4733548583
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 4161648583
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 4161648583
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 1672902310
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
NDC 1672902310
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.46
|
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 4733548583
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
BICARB HEMODIALYSIS SOLN WITHOUT CALCIUM NO 16 POT 4 MEQ-MAG 1.5 MEQ/L [121436]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
|
|
BICARB HEMODIALYSIS SOLN WITHOUT CALCIUM NO 16 POT 4 MEQ-MAG 1.5 MEQ/L [121436]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
BICARBONATE DIALYSIS SOLN WITHOUT CALCIUM NO15 POT 4 MEQ-MAG 1.2 MEQ/L [121260]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
BICARBONATE DIALYSIS SOLN WITHOUT CALCIUM NO15 POT 4 MEQ-MAG 1.2 MEQ/L [121260]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
|
|
BICARBONATE HEMODIALYSIS SOLUTION NO.2 K 2 MEQ-CA 3.5 MEQ-MG 1 MEQ/L [120070]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS A4706
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
BICARBONATE HEMODIALYSIS SOLUTION NO.2 K 2 MEQ-CA 3.5 MEQ-MG 1 MEQ/L [120070]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS A4706
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
|
|
BICARBONATE HEMODIALYSIS SOLUTION NO.9 K 4 MEQ-CA 2.5 MEQ-MG 1.5 MEQ/L [100176]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
|
|
BICARBONATE HEMODIALYSIS SOLUTION NO.9 K 4 MEQ-CA 2.5 MEQ-MG 1.5 MEQ/L [100176]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET [221141]
|
Facility
|
IP
|
$168.64
|
|
|
Service Code
|
NDC 6195825013
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.52 |
| Max. Negotiated Rate |
$126.48 |
| Rate for Payer: Adventist Health Commercial |
$33.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$108.60
|
| Rate for Payer: Cash Price |
$75.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$91.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$114.17
|
| Rate for Payer: Heritage Provider Network Senior |
$114.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$30.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.16
|
| Rate for Payer: Multiplan Commercial |
$126.48
|
|
|
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET [221141]
|
Facility
|
OP
|
$168.64
|
|
|
Service Code
|
NDC 6195825011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.52 |
| Max. Negotiated Rate |
$143.34 |
| Rate for Payer: Adventist Health Commercial |
$33.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$104.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$143.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$92.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$126.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$84.35
|
| Rate for Payer: Blue Shield of California Commercial |
$102.87
|
| Rate for Payer: Blue Shield of California EPN |
$82.30
|
| Rate for Payer: Cash Price |
$75.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$143.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$143.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$143.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$104.39
|
| Rate for Payer: Heritage Provider Network Senior |
$104.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$80.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$30.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$118.05
|
| Rate for Payer: Multiplan Commercial |
$126.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$67.46
|
| Rate for Payer: TriValley Medical Group Senior |
$67.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$84.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$84.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$143.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$143.34
|
| Rate for Payer: Vantage Medical Group Senior |
$143.34
|
|
|
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET [221141]
|
Facility
|
IP
|
$168.64
|
|
|
Service Code
|
NDC 6195825011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.52 |
| Max. Negotiated Rate |
$126.48 |
| Rate for Payer: Adventist Health Commercial |
$33.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$108.60
|
| Rate for Payer: Cash Price |
$75.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$91.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$114.17
|
| Rate for Payer: Heritage Provider Network Senior |
$114.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$30.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.16
|
| Rate for Payer: Multiplan Commercial |
$126.48
|
|
|
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET [221141]
|
Facility
|
OP
|
$168.64
|
|
|
Service Code
|
NDC 6195825013
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.52 |
| Max. Negotiated Rate |
$143.34 |
| Rate for Payer: Adventist Health Commercial |
$33.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$104.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$143.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$92.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$126.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$84.35
|
| Rate for Payer: Blue Shield of California Commercial |
$102.87
|
| Rate for Payer: Blue Shield of California EPN |
$82.30
|
| Rate for Payer: Cash Price |
$75.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$143.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$143.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$143.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$104.39
|
| Rate for Payer: Heritage Provider Network Senior |
$104.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$80.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$30.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$118.05
|
| Rate for Payer: Multiplan Commercial |
$126.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$67.46
|
| Rate for Payer: TriValley Medical Group Senior |
$67.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$84.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$84.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$143.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$143.34
|
| Rate for Payer: Vantage Medical Group Senior |
$143.34
|
|
|
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC
|
Facility
|
IP
|
$85,509.84
|
|
|
Service Code
|
MSDRG 461
|
| Min. Negotiated Rate |
$9,944.00 |
| Max. Negotiated Rate |
$85,509.84 |
| Rate for Payer: EPIC Health Plan Medicare |
$63,813.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$63,813.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$9,944.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$73,385.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$85,509.84
|
|
|
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC
|
Facility
|
IP
|
$41,547.14
|
|
|
Service Code
|
MSDRG 462
|
| Min. Negotiated Rate |
$9,944.00 |
| Max. Negotiated Rate |
$41,547.14 |
| Rate for Payer: EPIC Health Plan Medicare |
$31,005.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$31,005.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$9,944.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$35,656.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$41,547.14
|
|
