|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
OP
|
$0.06
|
|
|
Service Code
|
NDC 69097-845-07
|
| Hospital Charge Code |
1712380
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
IP
|
$0.06
|
|
|
Service Code
|
NDC 69097-845-07
|
| Hospital Charge Code |
1712380
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
IP
|
$0.82
|
|
|
Service Code
|
NDC 50268-190-11
|
| Hospital Charge Code |
1712380
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 43547-399-10
|
| Hospital Charge Code |
1712380
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
IP
|
$0.60
|
|
|
Service Code
|
NDC 68084-753-25
|
| Hospital Charge Code |
1712380
|
|
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 |
$0.41
|
| 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 Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
OP
|
$0.60
|
|
|
Service Code
|
NDC 68084-753-95
|
| Hospital Charge Code |
1712380
|
|
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 Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
OP
|
$0.82
|
|
|
Service Code
|
NDC 50268-190-11
|
| Hospital Charge Code |
1712380
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.70
|
| Rate for Payer: Dignity Health Senior |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Vantage Medical Group Senior |
$0.70
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
IP
|
$0.60
|
|
|
Service Code
|
NDC 68084-753-95
|
| Hospital Charge Code |
1712380
|
|
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 |
$0.41
|
| 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 Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 0378-0771-01
|
| Hospital Charge Code |
1712380
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| 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 |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
OP
|
$0.60
|
|
|
Service Code
|
NDC 68084-753-25
|
| Hospital Charge Code |
1712380
|
|
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 Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 0378-0771-01
|
| Hospital Charge Code |
1712380
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
NDC 43547-399-10
|
| Hospital Charge Code |
1712380
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
OP
|
$2.24
|
|
|
Service Code
|
NDC 61314-396-03
|
| Hospital Charge Code |
1740075
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Senior |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.90
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
OP
|
$7.17
|
|
|
Service Code
|
NDC 61314-396-01
|
| Hospital Charge Code |
1740068
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$6.09 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.93
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.38
|
| Rate for Payer: Blue Shield of California Commercial |
$4.45
|
| Rate for Payer: Blue Shield of California EPN |
$4.21
|
| Rate for Payer: Cash Price |
$3.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.09
|
| Rate for Payer: Dignity Health Senior |
$6.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.44
|
| Rate for Payer: Heritage Provider Network Senior |
$4.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$5.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.09
|
| Rate for Payer: Vantage Medical Group Senior |
$6.09
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
IP
|
$2.24
|
|
|
Service Code
|
NDC 61314-396-03
|
| Hospital Charge Code |
1740075
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.54
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
IP
|
$7.17
|
|
|
Service Code
|
NDC 61314-396-01
|
| Hospital Charge Code |
1740068
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$5.38 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.93
|
| Rate for Payer: Cash Price |
$3.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.85
|
| Rate for Payer: Heritage Provider Network Senior |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$5.38
|
|
|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS [9701]
|
Facility
OP
|
$19.96
|
|
|
Service Code
|
NDC 0065-0359-02
|
| Hospital Charge Code |
1740343
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$16.97 |
| Rate for Payer: Adventist Health Commercial |
$3.99
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.97
|
| Rate for Payer: Blue Shield of California Commercial |
$12.40
|
| Rate for Payer: Blue Shield of California EPN |
$11.72
|
| Rate for Payer: Cash Price |
$8.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.97
|
| Rate for Payer: Dignity Health Senior |
$16.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.36
|
| Rate for Payer: Heritage Provider Network Senior |
$12.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.99
|
| Rate for Payer: Multiplan Commercial |
$14.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.97
|
| Rate for Payer: Vantage Medical Group Senior |
$16.97
|
|
|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS [9701]
|
Facility
IP
|
$19.96
|
|
|
Service Code
|
NDC 0065-0359-02
|
| Hospital Charge Code |
1740343
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$14.97 |
| Rate for Payer: Adventist Health Commercial |
$3.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.71
|
| Rate for Payer: Cash Price |
$8.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.51
|
| Rate for Payer: Heritage Provider Network Senior |
$13.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.99
|
| Rate for Payer: Multiplan Commercial |
$14.97
|
|
|
CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]
|
Facility
OP
|
$879.00
|
|
|
Service Code
|
CPT J9070
|
| Hospital Charge Code |
1755736
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.77 |
| Max. Negotiated Rate |
$659.25 |
| Rate for Payer: Adventist Health Commercial |
$175.80
|
| Rate for Payer: Adventist Health Commercial |
$134.49
|
| Rate for Payer: Adventist Health Commercial |
$158.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$603.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$461.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$543.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$25.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$25.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$25.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$22.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$22.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$22.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$22.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$22.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$22.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.77
|
| Rate for Payer: Blue Shield of California Commercial |
$63.12
|
| Rate for Payer: Blue Shield of California Commercial |
$63.12
|
| Rate for Payer: Blue Shield of California Commercial |
$63.12
|
| Rate for Payer: Blue Shield of California EPN |
$63.12
|
| Rate for Payer: Blue Shield of California EPN |
$63.12
|
| Rate for Payer: Blue Shield of California EPN |
$63.12
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cash Price |
$395.55
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cash Price |
$302.59
|
| Rate for Payer: Cash Price |
$302.59
|
| Rate for Payer: Cash Price |
$395.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$309.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$363.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$404.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.17
|
| Rate for Payer: Dignity Health Senior |
$22.17
|
| Rate for Payer: Dignity Health Senior |
$22.17
|
| Rate for Payer: Dignity Health Senior |
$22.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$430.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$562.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$506.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$406.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$366.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$311.34
|
| Rate for Payer: Heritage Provider Network Senior |
$406.98
|
| Rate for Payer: Heritage Provider Network Senior |
$311.34
|
| Rate for Payer: Heritage Provider Network Senior |
$366.28
|
| Rate for Payer: Humana Medicare |
$20.15
|
| Rate for Payer: Humana Medicare |
$20.15
|
| Rate for Payer: Humana Medicare |
$20.15
|
| Rate for Payer: IEHP Medicare Advantage |
$20.15
|
| Rate for Payer: IEHP Medicare Advantage |
$20.15
|
| Rate for Payer: IEHP Medicare Advantage |
$20.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$143.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$121.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$159.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$197.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$219.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.39
|
| Rate for Payer: Multiplan Commercial |
$593.32
|
| Rate for Payer: Multiplan Commercial |
$504.32
|
| Rate for Payer: Multiplan Commercial |
$659.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.17
|
| Rate for Payer: TriValley Medical Group Senior |
$20.15
|
| Rate for Payer: TriValley Medical Group Senior |
$20.15
|
| Rate for Payer: TriValley Medical Group Senior |
$20.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$245.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$320.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$288.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$224.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$293.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$264.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.17
|
| Rate for Payer: Vantage Medical Group Senior |
$20.15
|
| Rate for Payer: Vantage Medical Group Senior |
$20.15
|
| Rate for Payer: Vantage Medical Group Senior |
$20.15
|
|
|
CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]
|
Facility
IP
|
$791.10
|
|
|
Service Code
|
CPT J9070
|
| Hospital Charge Code |
1755736
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$143.19 |
| Max. Negotiated Rate |
$593.32 |
| Rate for Payer: Adventist Health Commercial |
$158.22
|
| Rate for Payer: Adventist Health Commercial |
$134.49
|
| Rate for Payer: Adventist Health Commercial |
$175.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$603.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$543.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$461.96
|
| Rate for Payer: Cash Price |
$302.59
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cash Price |
$395.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$363.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$404.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$309.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$427.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$474.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$363.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$595.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$455.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$535.57
|
| Rate for Payer: Heritage Provider Network Senior |
$455.24
|
| Rate for Payer: Heritage Provider Network Senior |
$535.57
|
| Rate for Payer: Heritage Provider Network Senior |
$595.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$121.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$143.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$159.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$219.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$197.78
|
| Rate for Payer: Multiplan Commercial |
$593.32
|
| Rate for Payer: Multiplan Commercial |
$504.32
|
| Rate for Payer: Multiplan Commercial |
$659.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$288.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$245.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$320.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$264.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$224.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$293.67
|
|
|
CYCLOPHOSPHAMIDE 25 MG CAPSULE [206105]
|
Facility
IP
|
$3.60
|
|
|
Service Code
|
CPT J8530
|
| Hospital Charge Code |
ERX206105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$4.06
|
| Rate for Payer: Heritage Provider Network Senior |
$2.74
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$3.03
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.00
|
|
|
CYCLOPHOSPHAMIDE 25 MG CAPSULE [206105]
|
Facility
OP
|
$4.04
|
|
|
Service Code
|
CPT J8530
|
| Hospital Charge Code |
ERX206105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.46 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.46
|
| Rate for Payer: Blue Shield of California Commercial |
$3.25
|
| Rate for Payer: Blue Shield of California Commercial |
$3.25
|
| Rate for Payer: Blue Shield of California Commercial |
$3.25
|
| Rate for Payer: Blue Shield of California EPN |
$3.25
|
| Rate for Payer: Blue Shield of California EPN |
$3.25
|
| Rate for Payer: Blue Shield of California EPN |
$3.25
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.43
|
| Rate for Payer: Dignity Health Senior |
$3.06
|
| Rate for Payer: Dignity Health Senior |
$3.43
|
| Rate for Payer: Dignity Health Senior |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.78
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2.78
|
| Rate for Payer: Heritage Provider Network Senior |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$3.03
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$3.43
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION [28922]
|
Facility
OP
|
$1,758.00
|
|
|
Service Code
|
CPT J9070
|
| Hospital Charge Code |
1755757
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.77 |
| Max. Negotiated Rate |
$1,318.50 |
| Rate for Payer: Adventist Health Commercial |
$351.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,207.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$25.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$22.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$22.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.77
|
| Rate for Payer: Blue Shield of California Commercial |
$63.12
|
| Rate for Payer: Blue Shield of California EPN |
$63.12
|
| Rate for Payer: Cash Price |
$791.10
|
| Rate for Payer: Cash Price |
$791.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$808.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.17
|
| Rate for Payer: Dignity Health Senior |
$22.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,125.12
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$813.95
|
| Rate for Payer: Heritage Provider Network Senior |
$813.95
|
| Rate for Payer: Humana Medicare |
$20.15
|
| Rate for Payer: IEHP Medicare Advantage |
$20.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$318.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$439.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.39
|
| Rate for Payer: Multiplan Commercial |
$1,318.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.17
|
| Rate for Payer: TriValley Medical Group Senior |
$20.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$640.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$587.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.17
|
| Rate for Payer: Vantage Medical Group Senior |
$20.15
|
|
|
CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION [28922]
|
Facility
IP
|
$1,758.00
|
|
|
Service Code
|
CPT J9070
|
| Hospital Charge Code |
1755757
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$318.20 |
| Max. Negotiated Rate |
$1,318.50 |
| Rate for Payer: Adventist Health Commercial |
$351.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,207.75
|
| Rate for Payer: Cash Price |
$791.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$808.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$949.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,190.17
|
| Rate for Payer: Heritage Provider Network Senior |
$1,190.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$318.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$439.50
|
| Rate for Payer: Multiplan Commercial |
$1,318.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$640.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$587.35
|
|
|
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [38271]
|
Facility
OP
|
$222.00
|
|
|
Service Code
|
CPT J9070
|
| Hospital Charge Code |
ERX38271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.77 |
| Max. Negotiated Rate |
$166.50 |
| Rate for Payer: Adventist Health Commercial |
$44.40
|
| Rate for Payer: Adventist Health Commercial |
$67.25
|
| Rate for Payer: Adventist Health Commercial |
$87.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$152.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$301.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$230.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$25.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$25.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$25.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$22.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$22.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$22.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$22.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$22.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$22.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.77
|
| Rate for Payer: Blue Shield of California Commercial |
$63.12
|
| Rate for Payer: Blue Shield of California Commercial |
$63.12
|
| Rate for Payer: Blue Shield of California Commercial |
$63.12
|
| Rate for Payer: Blue Shield of California EPN |
$63.12
|
| Rate for Payer: Blue Shield of California EPN |
$63.12
|
| Rate for Payer: Blue Shield of California EPN |
$63.12
|
| Rate for Payer: Cash Price |
$151.30
|
| Rate for Payer: Cash Price |
$197.78
|
| Rate for Payer: Cash Price |
$197.78
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cash Price |
$151.30
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$102.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$154.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$202.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.17
|
| Rate for Payer: Dignity Health Senior |
$22.17
|
| Rate for Payer: Dignity Health Senior |
$22.17
|
| Rate for Payer: Dignity Health Senior |
$22.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$281.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$142.08
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$155.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$102.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$203.49
|
| Rate for Payer: Heritage Provider Network Senior |
$203.49
|
| Rate for Payer: Heritage Provider Network Senior |
$102.79
|
| Rate for Payer: Heritage Provider Network Senior |
$155.67
|
| Rate for Payer: Humana Medicare |
$20.15
|
| Rate for Payer: Humana Medicare |
$20.15
|
| Rate for Payer: Humana Medicare |
$20.15
|
| Rate for Payer: IEHP Medicare Advantage |
$20.15
|
| Rate for Payer: IEHP Medicare Advantage |
$20.15
|
| Rate for Payer: IEHP Medicare Advantage |
$20.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$79.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.39
|
| Rate for Payer: Multiplan Commercial |
$329.62
|
| Rate for Payer: Multiplan Commercial |
$166.50
|
| Rate for Payer: Multiplan Commercial |
$252.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.17
|
| Rate for Payer: TriValley Medical Group Senior |
$20.15
|
| Rate for Payer: TriValley Medical Group Senior |
$20.15
|
| Rate for Payer: TriValley Medical Group Senior |
$20.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$80.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$122.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$160.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$112.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$146.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$74.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.17
|
| Rate for Payer: Vantage Medical Group Senior |
$20.15
|
| Rate for Payer: Vantage Medical Group Senior |
$20.15
|
| Rate for Payer: Vantage Medical Group Senior |
$20.15
|
|
