|
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [38271]
|
Facility
IP
|
$222.00
|
|
|
Service Code
|
CPT J9070
|
| Hospital Charge Code |
ERX38271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.18 |
| Max. Negotiated Rate |
$166.50 |
| Rate for Payer: Adventist Health Commercial |
$44.40
|
| Rate for Payer: Adventist Health Commercial |
$87.90
|
| Rate for Payer: Adventist Health Commercial |
$67.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$152.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$230.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$301.94
|
| Rate for Payer: Cash Price |
$197.78
|
| Rate for Payer: Cash Price |
$151.30
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$154.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$102.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$202.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$119.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$237.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$181.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$227.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$297.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$150.29
|
| Rate for Payer: Heritage Provider Network Senior |
$150.29
|
| Rate for Payer: Heritage Provider Network Senior |
$227.63
|
| Rate for Payer: Heritage Provider Network Senior |
$297.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$79.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.50
|
| Rate for Payer: Multiplan Commercial |
$329.62
|
| Rate for Payer: Multiplan Commercial |
$166.50
|
| Rate for Payer: Multiplan Commercial |
$252.17
|
| 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+ |
$74.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$112.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$146.84
|
|
|
CYCLOPHOSPHAMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080261]
|
Facility
OP
|
$5.30
|
|
|
Service Code
|
NDC 9994-0802-61
|
| Hospital Charge Code |
1715018
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.98
|
| Rate for Payer: Blue Shield of California Commercial |
$3.29
|
| Rate for Payer: Blue Shield of California EPN |
$3.11
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.50
|
| Rate for Payer: Dignity Health Senior |
$4.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.28
|
| Rate for Payer: Heritage Provider Network Senior |
$3.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.50
|
| Rate for Payer: Vantage Medical Group Senior |
$4.50
|
|
|
CYCLOPHOSPHAMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080261]
|
Facility
IP
|
$5.30
|
|
|
Service Code
|
NDC 9994-0802-61
|
| Hospital Charge Code |
1715018
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$3.98 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.64
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Senior |
$3.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS [216389]
|
Facility
IP
|
$140.87
|
|
|
Service Code
|
NDC 0023-5301-05
|
| Hospital Charge Code |
NDG216389
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$105.65 |
| Rate for Payer: Adventist Health Commercial |
$28.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$96.78
|
| Rate for Payer: Cash Price |
$63.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$95.37
|
| Rate for Payer: Heritage Provider Network Senior |
$95.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.22
|
| Rate for Payer: Multiplan Commercial |
$105.65
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS [216389]
|
Facility
OP
|
$140.87
|
|
|
Service Code
|
NDC 0023-5301-05
|
| Hospital Charge Code |
NDG216389
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$119.74 |
| Rate for Payer: Adventist Health Commercial |
$28.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$75.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$96.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$119.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$77.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$105.65
|
| Rate for Payer: Blue Shield of California Commercial |
$87.48
|
| Rate for Payer: Blue Shield of California EPN |
$82.69
|
| Rate for Payer: Cash Price |
$63.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$119.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$119.74
|
| Rate for Payer: Dignity Health Senior |
$119.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$90.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$87.20
|
| Rate for Payer: Heritage Provider Network Senior |
$87.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$67.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.22
|
| Rate for Payer: Multiplan Commercial |
$105.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$119.74
|
| Rate for Payer: Vantage Medical Group Senior |
$119.74
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [35209]
|
Facility
IP
|
$5.60
|
|
|
Service Code
|
NDC 60505-6202-1
|
| Hospital Charge Code |
1740336
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.85
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.79
|
| Rate for Payer: Heritage Provider Network Senior |
$3.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.20
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [35209]
|
Facility
OP
|
$5.60
|
|
|
Service Code
|
NDC 60505-6202-1
|
| Hospital Charge Code |
1740336
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$4.76 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.20
|
| Rate for Payer: Blue Shield of California Commercial |
$3.48
|
| Rate for Payer: Blue Shield of California EPN |
$3.29
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.76
|
| Rate for Payer: Dignity Health Senior |
$4.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Senior |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.76
|
| Rate for Payer: Vantage Medical Group Senior |
$4.76
|
|
|
CYCLOSPORINE 100 MG CAPSULE [9706]
|
Facility
IP
|
$20.24
|
|
|
Service Code
|
CPT J7502
|
| Hospital Charge Code |
1711475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$15.18 |
| Rate for Payer: Adventist Health Commercial |
$4.05
|
| Rate for Payer: Adventist Health Commercial |
$2.95
|
| Rate for Payer: Adventist Health Commercial |
$4.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.90
|
| Rate for Payer: Cash Price |
$6.63
|
| Rate for Payer: Cash Price |
$9.12
|
| Rate for Payer: Cash Price |
$9.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.98
|
| Rate for Payer: Heritage Provider Network Senior |
$9.98
|
| Rate for Payer: Heritage Provider Network Senior |
$13.70
|
| Rate for Payer: Heritage Provider Network Senior |
$13.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.68
|
| Rate for Payer: Multiplan Commercial |
$11.06
|
| Rate for Payer: Multiplan Commercial |
$15.20
|
| Rate for Payer: Multiplan Commercial |
$15.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.77
|
|
|
CYCLOSPORINE 100 MG CAPSULE [9706]
|
Facility
OP
|
$20.24
|
|
|
Service Code
|
CPT J7502
|
| Hospital Charge Code |
1711475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$17.20 |
| Rate for Payer: Adventist Health Commercial |
$4.05
|
| Rate for Payer: Adventist Health Commercial |
$2.95
|
| Rate for Payer: Adventist Health Commercial |
$4.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.97
|
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$4.49
|
| Rate for Payer: Cash Price |
$9.12
|
| Rate for Payer: Cash Price |
$9.11
|
| Rate for Payer: Cash Price |
$9.11
|
| Rate for Payer: Cash Price |
$9.12
|
| Rate for Payer: Cash Price |
$6.63
|
| Rate for Payer: Cash Price |
$6.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.23
|
| Rate for Payer: Dignity Health Senior |
$17.20
|
| Rate for Payer: Dignity Health Senior |
$17.23
|
| Rate for Payer: Dignity Health Senior |
$12.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.39
|
| Rate for Payer: Heritage Provider Network Senior |
$9.39
|
| Rate for Payer: Heritage Provider Network Senior |
$6.82
|
| Rate for Payer: Heritage Provider Network Senior |
$9.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.07
|
| Rate for Payer: Multiplan Commercial |
$15.20
|
| Rate for Payer: Multiplan Commercial |
$11.06
|
| Rate for Payer: Multiplan Commercial |
$15.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.53
|
| Rate for Payer: Vantage Medical Group Senior |
$12.53
|
| Rate for Payer: Vantage Medical Group Senior |
$17.20
|
| Rate for Payer: Vantage Medical Group Senior |
$17.23
|
|
|
CYCLOSPORINE 100 MG/ML ORAL SOLUTION [9708]
|
Facility
OP
|
$19.66
|
|
|
Service Code
|
CPT J7502
|
| Hospital Charge Code |
1719136
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$16.71 |
| Rate for Payer: Adventist Health Commercial |
$3.93
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.97
|
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$4.49
|
| Rate for Payer: Cash Price |
$8.85
|
| Rate for Payer: Cash Price |
$8.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.71
|
| Rate for Payer: Dignity Health Senior |
$16.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.10
|
| Rate for Payer: Heritage Provider Network Senior |
$9.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.92
|
| Rate for Payer: Multiplan Commercial |
$14.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.71
|
| Rate for Payer: Vantage Medical Group Senior |
$16.71
|
|
|
CYCLOSPORINE 100 MG/ML ORAL SOLUTION [9708]
|
Facility
IP
|
$19.66
|
|
|
Service Code
|
CPT J7502
|
| Hospital Charge Code |
1719136
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$14.74 |
| Rate for Payer: Adventist Health Commercial |
$3.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.51
|
| Rate for Payer: Cash Price |
$8.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.31
|
| Rate for Payer: Heritage Provider Network Senior |
$13.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.92
|
| Rate for Payer: Multiplan Commercial |
$14.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.57
|
|
|
CYCLOSPORINE 250 MG/5 ML INTRAVENOUS SOLUTION [9705]
|
Facility
OP
|
$15.78
|
|
|
Service Code
|
CPT J7516
|
| Hospital Charge Code |
NDG9705
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$94.74 |
| Rate for Payer: Adventist Health Commercial |
$3.16
|
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$94.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$94.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$57.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$57.76
|
| Rate for Payer: Blue Shield of California Commercial |
$39.89
|
| Rate for Payer: Blue Shield of California Commercial |
$39.89
|
| Rate for Payer: Blue Shield of California EPN |
$39.89
|
| Rate for Payer: Blue Shield of California EPN |
$39.89
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: Cash Price |
$7.10
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: Cash Price |
$7.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.98
|
| Rate for Payer: Dignity Health Senior |
$7.98
|
| Rate for Payer: Dignity Health Senior |
$13.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.31
|
| Rate for Payer: Heritage Provider Network Senior |
$7.31
|
| Rate for Payer: Heritage Provider Network Senior |
$4.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$7.04
|
| Rate for Payer: Multiplan Commercial |
$11.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.98
|
| Rate for Payer: Vantage Medical Group Senior |
$7.98
|
| Rate for Payer: Vantage Medical Group Senior |
$13.41
|
|
|
CYCLOSPORINE 250 MG/5 ML INTRAVENOUS SOLUTION [9705]
|
Facility
IP
|
$15.78
|
|
|
Service Code
|
CPT J7516
|
| Hospital Charge Code |
NDG9705
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$11.84 |
| Rate for Payer: Adventist Health Commercial |
$3.16
|
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.45
|
| Rate for Payer: Cash Price |
$7.10
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.36
|
| Rate for Payer: Heritage Provider Network Senior |
$10.68
|
| Rate for Payer: Heritage Provider Network Senior |
$6.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.94
|
| Rate for Payer: Multiplan Commercial |
$11.84
|
| Rate for Payer: Multiplan Commercial |
$7.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.14
|
|
|
CYCLOSPORINE 25 MG CAPSULE [9707]
|
Facility
IP
|
$5.07
|
|
|
Service Code
|
CPT J7515
|
| Hospital Charge Code |
1711480
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Adventist Health Commercial |
$1.01
|
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.52
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.43
|
| Rate for Payer: Heritage Provider Network Senior |
$3.43
|
| Rate for Payer: Heritage Provider Network Senior |
$3.47
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.80
|
| Rate for Payer: Multiplan Commercial |
$2.77
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.71
|
|
|
CYCLOSPORINE 25 MG CAPSULE [9707]
|
Facility
OP
|
$3.69
|
|
|
Service Code
|
CPT J7515
|
| Hospital Charge Code |
1711480
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$3.14 |
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Adventist Health Commercial |
$1.01
|
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.77
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.14
|
| Rate for Payer: Dignity Health Senior |
$3.14
|
| Rate for Payer: Dignity Health Senior |
$4.31
|
| Rate for Payer: Dignity Health Senior |
$4.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.37
|
| Rate for Payer: Heritage Provider Network Senior |
$2.37
|
| Rate for Payer: Heritage Provider Network Senior |
$2.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$2.77
|
| Rate for Payer: Multiplan Commercial |
$3.80
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.14
|
| Rate for Payer: Vantage Medical Group Senior |
$4.31
|
| Rate for Payer: Vantage Medical Group Senior |
$4.35
|
|
|
CYCLOSPORINE MODIFIED 100 MG CAPSULE [28843]
|
Facility
IP
|
$8.40
|
|
|
Service Code
|
CPT J7502
|
| Hospital Charge Code |
1712179
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$6.30 |
| Rate for Payer: Adventist Health Commercial |
$1.68
|
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.63
|
| Rate for Payer: Cash Price |
$3.78
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.69
|
| Rate for Payer: Heritage Provider Network Senior |
$5.69
|
| Rate for Payer: Heritage Provider Network Senior |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$6.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.76
|
|
|
CYCLOSPORINE MODIFIED 100 MG CAPSULE [28843]
|
Facility
OP
|
$8.40
|
|
|
Service Code
|
CPT J7502
|
| Hospital Charge Code |
1712179
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$9.97 |
| Rate for Payer: Adventist Health Commercial |
$1.68
|
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.63
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.97
|
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$4.49
|
| Rate for Payer: Cash Price |
$3.78
|
| Rate for Payer: Cash Price |
$3.78
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.49
|
| Rate for Payer: Dignity Health Senior |
$4.49
|
| Rate for Payer: Dignity Health Senior |
$7.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.89
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$3.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$6.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.14
|
| Rate for Payer: Vantage Medical Group Senior |
$4.49
|
| Rate for Payer: Vantage Medical Group Senior |
$7.14
|
|
|
CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLUTION [28844]
|
Facility
IP
|
$5.66
|
|
|
Service Code
|
CPT J7502
|
| Hospital Charge Code |
NDG28844
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Adventist Health Commercial |
$1.13
|
| Rate for Payer: Adventist Health Commercial |
$2.72
|
| Rate for Payer: Adventist Health Commercial |
$1.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.89
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.20
|
| Rate for Payer: Heritage Provider Network Senior |
$3.83
|
| Rate for Payer: Heritage Provider Network Senior |
$9.20
|
| Rate for Payer: Heritage Provider Network Senior |
$6.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.42
|
| Rate for Payer: Multiplan Commercial |
$10.19
|
| Rate for Payer: Multiplan Commercial |
$4.24
|
| Rate for Payer: Multiplan Commercial |
$7.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.17
|
|
|
CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLUTION [28844]
|
Facility
OP
|
$5.66
|
|
|
Service Code
|
CPT J7502
|
| Hospital Charge Code |
NDG28844
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$9.97 |
| Rate for Payer: Adventist Health Commercial |
$1.13
|
| Rate for Payer: Adventist Health Commercial |
$1.90
|
| Rate for Payer: Adventist Health Commercial |
$2.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.97
|
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$4.49
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.07
|
| Rate for Payer: Dignity Health Senior |
$4.81
|
| Rate for Payer: Dignity Health Senior |
$8.07
|
| Rate for Payer: Dignity Health Senior |
$11.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.39
|
| Rate for Payer: Heritage Provider Network Senior |
$6.29
|
| Rate for Payer: Heritage Provider Network Senior |
$2.62
|
| Rate for Payer: Heritage Provider Network Senior |
$4.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$10.19
|
| Rate for Payer: Multiplan Commercial |
$7.12
|
| Rate for Payer: Multiplan Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.07
|
| Rate for Payer: Vantage Medical Group Senior |
$4.81
|
| Rate for Payer: Vantage Medical Group Senior |
$11.55
|
| Rate for Payer: Vantage Medical Group Senior |
$8.07
|
|
|
CYCLOSPORINE MODIFIED 25 MG CAPSULE [28842]
|
Facility
OP
|
$1.32
|
|
|
Service Code
|
CPT J7515
|
| Hospital Charge Code |
1712180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.12
|
| Rate for Payer: Dignity Health Senior |
$1.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Vantage Medical Group Senior |
$1.12
|
|
|
CYCLOSPORINE MODIFIED 25 MG CAPSULE [28842]
|
Facility
IP
|
$1.32
|
|
|
Service Code
|
CPT J7515
|
| Hospital Charge Code |
1712180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.44
|
|
|
CYPROHEPTADINE 4 MG TABLET [2033]
|
Facility
IP
|
$0.11
|
|
|
Service Code
|
NDC 50742-190-01
|
| Hospital Charge Code |
1710485
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
CYPROHEPTADINE 4 MG TABLET [2033]
|
Facility
OP
|
$0.78
|
|
|
Service Code
|
NDC 50268-189-15
|
| Hospital Charge Code |
1710485
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.66
|
| Rate for Payer: Dignity Health Senior |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Vantage Medical Group Senior |
$0.66
|
|
|
CYPROHEPTADINE 4 MG TABLET [2033]
|
Facility
OP
|
$0.78
|
|
|
Service Code
|
NDC 50268-189-11
|
| Hospital Charge Code |
1710485
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.66
|
| Rate for Payer: Dignity Health Senior |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Vantage Medical Group Senior |
$0.66
|
|
|
CYPROHEPTADINE 4 MG TABLET [2033]
|
Facility
IP
|
$0.78
|
|
|
Service Code
|
NDC 50268-189-15
|
| Hospital Charge Code |
1710485
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
