|
BISMUTH SUBSALICYLATE 525 MG/15 ML ORAL SUSPENSION [112159]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0536128736
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
BISMUTH SUBSALICYLATE 525 MG/15 ML ORAL SUSPENSION [112159]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 0149003929
|
| 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
|
|
|
BISMUTH SUBSALICYLATE 525 MG/15 ML ORAL SUSPENSION [112159]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 3700001901
|
| 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 |
$0.03
|
| 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 |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| 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 |
$0.03
|
| 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 |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| 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
|
|
|
BISMUTH SUBSALICYLATE 525 MG/15 ML ORAL SUSPENSION [112159]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 3700001901
|
| 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 |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| 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 |
$0.03
|
|
|
BISMUTH SUBSALICYLATE 525 MG/15 ML ORAL SUSPENSION [112159]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0149003930
|
| 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 |
$0.03
|
| 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 |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| 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 |
$0.03
|
| 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 |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| 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
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 5281727010
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 5026812711
|
| 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: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Cash Price |
$0.63
|
| 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 Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 2930012613
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 5281727030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 5026812715
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 2930012601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 5026812715
|
| 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: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Cash Price |
$0.63
|
| 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 Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 6068767911
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.00
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 2930012601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| 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 |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 2930012613
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 5281727030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 6068767911
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.78
|
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Senior |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 5026812711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 5281727010
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
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: Aetna of CA Non-Gatekeeper |
$69.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.10
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$37.80
|
| 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 |
$45.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.89
|
| Rate for Payer: Heritage Provider Network Senior |
$38.89
|
| Rate for Payer: Heritage Provider Network Senior |
$50.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.20
|
| 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: Multiplan Commercial |
$81.00
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| 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+ |
$27.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$35.76
|
|
|
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION [29396]
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
HCPCS J0583
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$91.80 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$66.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$91.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$71.40
|
| 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 |
$81.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$63.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.77
|
| 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 |
$48.60
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$37.80
|
| 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 |
$71.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$91.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$91.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$71.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.76
|
| 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 |
$38.89
|
| Rate for Payer: Heritage Provider Network Senior |
$50.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$51.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$40.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.55
|
| 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: Molina Healthcare of CA Medi-Cal/Medicare |
$58.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$75.60
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$81.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$33.60
|
| 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 |
$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
|
| 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 |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$91.80
|
|
|
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION [9289]
|
Facility
|
OP
|
$39.74
|
|
|
Service Code
|
HCPCS J9040
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.19 |
| Max. Negotiated Rate |
$656.46 |
| Rate for Payer: Adventist Health Commercial |
$7.95
|
| Rate for Payer: Adventist Health Commercial |
$12.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.47
|
| 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 |
$29.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$656.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$656.46
|
| 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 |
$17.88
|
| Rate for Payer: Cash Price |
$27.25
|
| Rate for Payer: Cash Price |
$17.88
|
| Rate for Payer: Cash Price |
$27.25
|
| 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 |
$51.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$33.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$51.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.75
|
| 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 |
$28.03
|
| Rate for Payer: Heritage Provider Network Senior |
$18.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$18.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$28.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.19
|
| 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: Molina Healthcare of CA Medi-Cal/Medicare |
$42.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$27.82
|
| Rate for Payer: Multiplan Commercial |
$45.41
|
| Rate for Payer: Multiplan Commercial |
$29.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.22
|
| 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 |
$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
|
| 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 |
$51.47
|
| Rate for Payer: Vantage Medical Group Senior |
$33.78
|
|
|
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: Aetna of CA Non-Gatekeeper |
$25.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.99
|
| Rate for Payer: Cash Price |
$17.88
|
| Rate for Payer: Cash Price |
$27.25
|
| 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 |
$32.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.03
|
| Rate for Payer: Heritage Provider Network Senior |
$28.03
|
| Rate for Payer: Heritage Provider Network Senior |
$18.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.96
|
| 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: Multiplan Commercial |
$29.80
|
| Rate for Payer: Multiplan Commercial |
$45.41
|
| 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+ |
$20.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.16
|
|
|
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: Aetna of CA Non-Gatekeeper |
$72.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.54
|
| Rate for Payer: Cash Price |
$50.55
|
| Rate for Payer: Cash Price |
$36.01
|
| 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 |
$43.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.05
|
| Rate for Payer: Heritage Provider Network Senior |
$37.05
|
| Rate for Payer: Heritage Provider Network Senior |
$52.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.49
|
| 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: Multiplan Commercial |
$84.25
|
| Rate for Payer: Multiplan Commercial |
$60.02
|
| 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+ |
$26.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.20
|
|
|
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION [17012]
|
Facility
|
OP
|
$112.34
|
|
|
Service Code
|
HCPCS J9040
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.33 |
| Max. Negotiated Rate |
$656.46 |
| Rate for Payer: Adventist Health Commercial |
$22.47
|
| Rate for Payer: Adventist Health Commercial |
$16.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$68.03
|
| 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 |
$84.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$60.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$656.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$656.46
|
| 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 |
$50.55
|
| Rate for Payer: Cash Price |
$36.01
|
| Rate for Payer: Cash Price |
$50.55
|
| Rate for Payer: Cash Price |
$36.01
|
| 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 |
$68.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$95.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$68.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.22
|
| 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 |
$37.05
|
| Rate for Payer: Heritage Provider Network Senior |
$52.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$53.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$38.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.33
|
| 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: Molina Healthcare of CA Medi-Cal/Medicare |
$56.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$78.64
|
| Rate for Payer: Multiplan Commercial |
$60.02
|
| Rate for Payer: Multiplan Commercial |
$84.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$44.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$32.01
|
| 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 |
$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
|
| 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 |
$68.03
|
| Rate for Payer: Vantage Medical Group Senior |
$95.49
|
|
