|
BOSENTAN 31.25 MG 1/2 TABLET [4081538]
|
Facility
|
OP
|
$17.45
|
|
|
Service Code
|
NDC 6838244614
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.73
|
| Rate for Payer: Blue Shield of California Commercial |
$10.64
|
| Rate for Payer: Blue Shield of California EPN |
$8.52
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.80
|
| Rate for Payer: Heritage Provider Network Senior |
$10.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.21
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.98
|
| Rate for Payer: TriValley Medical Group Senior |
$6.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.83
|
|
|
BOSENTAN 31.25 MG 1/2 TABLET [4081538]
|
Facility
|
IP
|
$17.45
|
|
|
Service Code
|
NDC 6838244614
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$13.09 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.24
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.81
|
| Rate for Payer: Heritage Provider Network Senior |
$11.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.36
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$17.45
|
|
|
Service Code
|
NDC 6838244614
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$13.09 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.24
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.81
|
| Rate for Payer: Heritage Provider Network Senior |
$11.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.36
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$276.32
|
|
|
Service Code
|
NDC 6621510103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.01 |
| Max. Negotiated Rate |
$207.24 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$177.95
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$149.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$187.07
|
| Rate for Payer: Heritage Provider Network Senior |
$187.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.08
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$17.45
|
|
|
Service Code
|
NDC 6838244614
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.78
|
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.73
|
| Rate for Payer: Blue Shield of California Commercial |
$10.64
|
| Rate for Payer: Blue Shield of California EPN |
$8.52
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.80
|
| Rate for Payer: Heritage Provider Network Senior |
$10.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.21
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.98
|
| Rate for Payer: TriValley Medical Group Senior |
$6.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.83
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$276.32
|
|
|
Service Code
|
NDC 6621510106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.01 |
| Max. Negotiated Rate |
$207.24 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$177.95
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$149.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$187.07
|
| Rate for Payer: Heritage Provider Network Senior |
$187.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.08
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$276.32
|
|
|
Service Code
|
NDC 6621510103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.01 |
| Max. Negotiated Rate |
$234.87 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$170.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.22
|
| Rate for Payer: Blue Shield of California Commercial |
$168.56
|
| Rate for Payer: Blue Shield of California EPN |
$134.84
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$179.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$234.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$234.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$176.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$171.04
|
| Rate for Payer: Heritage Provider Network Senior |
$171.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$131.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$193.42
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$110.53
|
| Rate for Payer: TriValley Medical Group Senior |
$110.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$138.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$138.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.87
|
| Rate for Payer: Vantage Medical Group Senior |
$234.87
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$276.32
|
|
|
Service Code
|
NDC 6621510106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.01 |
| Max. Negotiated Rate |
$234.87 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$170.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.22
|
| Rate for Payer: Blue Shield of California Commercial |
$168.56
|
| Rate for Payer: Blue Shield of California EPN |
$134.84
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$179.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$234.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$234.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$176.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$171.04
|
| Rate for Payer: Heritage Provider Network Senior |
$171.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$131.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$193.42
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$110.53
|
| Rate for Payer: TriValley Medical Group Senior |
$110.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$138.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$138.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.87
|
| Rate for Payer: Vantage Medical Group Senior |
$234.87
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
IP
|
$276.32
|
|
|
Service Code
|
NDC 6621510103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.01 |
| Max. Negotiated Rate |
$207.24 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$177.95
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$149.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$187.07
|
| Rate for Payer: Heritage Provider Network Senior |
$187.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.08
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
IP
|
$276.32
|
|
|
Service Code
|
NDC 6621510106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.01 |
| Max. Negotiated Rate |
$207.24 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$177.95
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$149.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$187.07
|
| Rate for Payer: Heritage Provider Network Senior |
$187.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.08
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
OP
|
$276.32
|
|
|
Service Code
|
NDC 6621510106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.01 |
| Max. Negotiated Rate |
$234.87 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$170.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.22
|
| Rate for Payer: Blue Shield of California Commercial |
$168.56
|
| Rate for Payer: Blue Shield of California EPN |
$134.84
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$179.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$234.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$234.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$176.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$171.04
|
| Rate for Payer: Heritage Provider Network Senior |
$171.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$131.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$193.42
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$110.53
|
| Rate for Payer: TriValley Medical Group Senior |
$110.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$138.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$138.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.87
|
| Rate for Payer: Vantage Medical Group Senior |
$234.87
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
OP
|
$276.32
|
|
|
Service Code
|
NDC 6621510103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.01 |
| Max. Negotiated Rate |
$234.87 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$170.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.22
|
| Rate for Payer: Blue Shield of California Commercial |
$168.56
|
| Rate for Payer: Blue Shield of California EPN |
$134.84
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$179.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$234.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$234.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$176.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$171.04
|
| Rate for Payer: Heritage Provider Network Senior |
$171.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$131.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$193.42
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$110.53
|
| Rate for Payer: TriValley Medical Group Senior |
$110.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$138.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$138.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.87
|
| Rate for Payer: Vantage Medical Group Senior |
$234.87
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
|
OP
|
$16.44
|
|
|
Service Code
|
NDC 9940831876
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$13.97 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.22
|
| Rate for Payer: Blue Shield of California Commercial |
$10.03
|
| Rate for Payer: Blue Shield of California EPN |
$8.02
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.18
|
| Rate for Payer: Heritage Provider Network Senior |
$10.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.51
|
| Rate for Payer: Multiplan Commercial |
$12.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.58
|
| Rate for Payer: TriValley Medical Group Senior |
$6.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.97
|
| Rate for Payer: Vantage Medical Group Senior |
$13.97
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
|
IP
|
$16.44
|
|
|
Service Code
|
NDC 9940831876
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$12.33 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.59
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.13
|
| Rate for Payer: Heritage Provider Network Senior |
$11.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Multiplan Commercial |
$12.33
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
|
OP
|
$222.48
|
|
|
Service Code
|
NDC 0069013501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$40.27 |
| Max. Negotiated Rate |
$189.11 |
| Rate for Payer: Adventist Health Commercial |
$44.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$137.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$189.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$122.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$166.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$111.28
|
| Rate for Payer: Blue Shield of California Commercial |
$135.71
|
| Rate for Payer: Blue Shield of California EPN |
$108.57
|
| Rate for Payer: Cash Price |
$100.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$144.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$189.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$189.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$189.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$142.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$137.72
|
| Rate for Payer: Heritage Provider Network Senior |
$137.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$106.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$40.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$155.74
|
| Rate for Payer: Multiplan Commercial |
$166.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$88.99
|
| Rate for Payer: TriValley Medical Group Senior |
$88.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$111.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$111.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$189.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$189.11
|
| Rate for Payer: Vantage Medical Group Senior |
$189.11
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
|
IP
|
$222.48
|
|
|
Service Code
|
NDC 0069013501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$40.27 |
| Max. Negotiated Rate |
$166.86 |
| Rate for Payer: Adventist Health Commercial |
$44.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$143.28
|
| Rate for Payer: Cash Price |
$100.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$120.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$150.62
|
| Rate for Payer: Heritage Provider Network Senior |
$150.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$40.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.62
|
| Rate for Payer: Multiplan Commercial |
$166.86
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
|
OP
|
$889.92
|
|
|
Service Code
|
NDC 0069019301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$161.08 |
| Max. Negotiated Rate |
$756.43 |
| Rate for Payer: Adventist Health Commercial |
$177.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$549.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$756.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$489.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$667.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$445.14
|
| Rate for Payer: Blue Shield of California Commercial |
$542.85
|
| Rate for Payer: Blue Shield of California EPN |
$434.28
|
| Rate for Payer: Cash Price |
$400.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$578.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$756.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$756.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$756.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$569.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$550.86
|
| Rate for Payer: Heritage Provider Network Senior |
$550.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$424.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$161.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$222.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$622.94
|
| Rate for Payer: Multiplan Commercial |
$667.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$355.97
|
| Rate for Payer: TriValley Medical Group Senior |
$355.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$444.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$444.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$756.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$756.43
|
| Rate for Payer: Vantage Medical Group Senior |
$756.43
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
|
IP
|
$889.92
|
|
|
Service Code
|
NDC 0069019301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$161.08 |
| Max. Negotiated Rate |
$667.44 |
| Rate for Payer: Adventist Health Commercial |
$177.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$573.11
|
| Rate for Payer: Cash Price |
$400.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$480.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$602.48
|
| Rate for Payer: Heritage Provider Network Senior |
$602.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$161.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$222.48
|
| Rate for Payer: Multiplan Commercial |
$667.44
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
|
IP
|
$889.92
|
|
|
Service Code
|
NDC 0069013601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$161.08 |
| Max. Negotiated Rate |
$667.44 |
| Rate for Payer: Adventist Health Commercial |
$177.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$573.11
|
| Rate for Payer: Cash Price |
$400.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$480.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$602.48
|
| Rate for Payer: Heritage Provider Network Senior |
$602.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$161.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$222.48
|
| Rate for Payer: Multiplan Commercial |
$667.44
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
|
OP
|
$889.92
|
|
|
Service Code
|
NDC 0069013601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$161.08 |
| Max. Negotiated Rate |
$756.43 |
| Rate for Payer: Adventist Health Commercial |
$177.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$549.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$756.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$489.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$667.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$445.14
|
| Rate for Payer: Blue Shield of California Commercial |
$542.85
|
| Rate for Payer: Blue Shield of California EPN |
$434.28
|
| Rate for Payer: Cash Price |
$400.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$578.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$756.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$756.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$756.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$569.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$550.86
|
| Rate for Payer: Heritage Provider Network Senior |
$550.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$424.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$161.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$222.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$622.94
|
| Rate for Payer: Multiplan Commercial |
$667.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$355.97
|
| Rate for Payer: TriValley Medical Group Senior |
$355.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$444.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$444.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$756.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$756.43
|
| Rate for Payer: Vantage Medical Group Senior |
$756.43
|
|
|
BOTULISM IMMUNE GLOBULIN, HUMAN 100 MG INTRAVENOUS SOLUTION [213747]
|
Facility
|
IP
|
$271,800.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49,195.80 |
| Max. Negotiated Rate |
$203,850.00 |
| Rate for Payer: Adventist Health Commercial |
$54,360.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$175,039.20
|
| Rate for Payer: Cash Price |
$122,310.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$125,028.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$146,772.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$125,843.40
|
| Rate for Payer: Heritage Provider Network Senior |
$125,843.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$49,195.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67,950.00
|
| Rate for Payer: Multiplan Commercial |
$203,850.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$98,201.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$89,992.98
|
|
|
BOTULISM IMMUNE GLOBULIN, HUMAN 100 MG INTRAVENOUS SOLUTION [213747]
|
Facility
|
OP
|
$271,800.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49,195.80 |
| Max. Negotiated Rate |
$231,030.00 |
| Rate for Payer: Adventist Health Commercial |
$54,360.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$167,972.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$231,030.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$149,490.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$203,850.00
|
| Rate for Payer: Blue Shield of California Commercial |
$165,798.00
|
| Rate for Payer: Blue Shield of California EPN |
$132,638.40
|
| Rate for Payer: Cash Price |
$122,310.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$125,028.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$231,030.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$231,030.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$231,030.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$173,952.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$125,843.40
|
| Rate for Payer: Heritage Provider Network Senior |
$125,843.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$129,648.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$49,195.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67,950.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$190,260.00
|
| Rate for Payer: Multiplan Commercial |
$203,850.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$108,720.00
|
| Rate for Payer: TriValley Medical Group Senior |
$108,720.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$98,201.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$89,992.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$231,030.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231,030.00
|
| Rate for Payer: Vantage Medical Group Senior |
$231,030.00
|
|
|
BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$33,573.06
|
|
|
Service Code
|
MSDRG 584
|
| Min. Negotiated Rate |
$25,054.52 |
| Max. Negotiated Rate |
$33,573.06 |
| Rate for Payer: EPIC Health Plan Medicare |
$25,054.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$25,054.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28,812.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$33,573.06
|
|
|
BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$30,323.81
|
|
|
Service Code
|
MSDRG 585
|
| Min. Negotiated Rate |
$22,629.71 |
| Max. Negotiated Rate |
$30,323.81 |
| Rate for Payer: EPIC Health Plan Medicare |
$22,629.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22,629.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$26,024.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$30,323.81
|
|
|
BREAST REDUCTION
|
Facility
|
OP
|
$16,226.70
|
|
|
Service Code
|
CPT 19318
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,178.49 |
| Max. Negotiated Rate |
$16,226.70 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9,394.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,540.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,136.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,394.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8,540.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$8,540.37
|
| Rate for Payer: Heritage Provider Network Senior |
$10,504.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,540.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$16,226.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9,821.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11,444.10
|
| Rate for Payer: Multiplan WC |
$13,202.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,394.41
|
| Rate for Payer: TriValley Medical Group Senior |
$9,394.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12,150.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10,259.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,394.41
|
| Rate for Payer: Vantage Medical Group Senior |
$8,540.37
|
|
