|
Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 52332
|
| Min. Negotiated Rate |
$858.98 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,791.29
|
| Rate for Payer: Dignity Health Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,355.72
|
| Rate for Payer: Humana Medicare |
$4,355.72
|
| Rate for Payer: IEHP Medi-Cal |
$858.98
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,275.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,139.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,488.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,488.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,791.29
|
| Rate for Payer: TriValley Medical Group Senior |
$4,355.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Cystourethroscopy, with insertion of permanent urethral stent
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 52282
|
| Min. Negotiated Rate |
$512.83 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,791.29
|
| Rate for Payer: Dignity Health Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,355.72
|
| Rate for Payer: Humana Medicare |
$4,355.72
|
| Rate for Payer: IEHP Medi-Cal |
$512.83
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,275.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,139.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,488.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,488.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,791.29
|
| Rate for Payer: TriValley Medical Group Senior |
$4,355.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 52310
|
| Min. Negotiated Rate |
$459.98 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,544.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,799.36
|
| Rate for Payer: Dignity Health Senior |
$2,544.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,544.87
|
| Rate for Payer: Humana Medicare |
$2,544.87
|
| Rate for Payer: IEHP Medi-Cal |
$459.98
|
| Rate for Payer: IEHP Medicare Advantage |
$2,544.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,835.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,002.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,206.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,206.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,799.36
|
| Rate for Payer: TriValley Medical Group Senior |
$2,544.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Vantage Medical Group Senior |
$2,544.87
|
|
|
Cystourethroscopy; with resection or fulguration of orthotopic ureterocele(s), unilateral or bilateral
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 52300
|
| Min. Negotiated Rate |
$354.87 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,791.29
|
| Rate for Payer: Dignity Health Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,355.72
|
| Rate for Payer: Humana Medicare |
$4,355.72
|
| Rate for Payer: IEHP Medi-Cal |
$354.87
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,275.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,139.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,488.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,488.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,791.29
|
| Rate for Payer: TriValley Medical Group Senior |
$4,355.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Cystourethroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 52341
|
| Min. Negotiated Rate |
$438.50 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,791.29
|
| Rate for Payer: Dignity Health Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,355.72
|
| Rate for Payer: Humana Medicare |
$4,355.72
|
| Rate for Payer: IEHP Medi-Cal |
$438.50
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,275.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,139.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,488.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,488.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,791.29
|
| Rate for Payer: TriValley Medical Group Senior |
$4,355.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Cystourethroscopy; with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, electrocautery, and incision)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 52342
|
| Min. Negotiated Rate |
$474.51 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,791.29
|
| Rate for Payer: Dignity Health Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,355.72
|
| Rate for Payer: Humana Medicare |
$4,355.72
|
| Rate for Payer: IEHP Medi-Cal |
$474.51
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,275.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,139.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,488.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,488.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,791.29
|
| Rate for Payer: TriValley Medical Group Senior |
$4,355.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service;
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 52005
|
| Min. Negotiated Rate |
$236.96 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,544.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,799.36
|
| Rate for Payer: Dignity Health Senior |
$2,544.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,544.87
|
| Rate for Payer: Humana Medicare |
$2,544.87
|
| Rate for Payer: IEHP Medi-Cal |
$236.96
|
| Rate for Payer: IEHP Medicare Advantage |
$2,544.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,835.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,002.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,206.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,206.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,799.36
|
| Rate for Payer: TriValley Medical Group Senior |
$2,544.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Vantage Medical Group Senior |
$2,544.87
|
|
|
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 52351
|
| Min. Negotiated Rate |
$406.55 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,791.29
|
| Rate for Payer: Dignity Health Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,355.72
|
| Rate for Payer: Humana Medicare |
$4,355.72
|
| Rate for Payer: IEHP Medi-Cal |
$406.55
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,275.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,139.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,488.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,488.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,791.29
|
| Rate for Payer: TriValley Medical Group Senior |
$4,355.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion
|
Facility
OP
|
$12,283.52
|
|
|
Service Code
|
CPT 52354
|
| Min. Negotiated Rate |
$509.93 |
| Max. Negotiated Rate |
$12,283.52 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,465.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,111.51
|
| Rate for Payer: Dignity Health Senior |
$6,465.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,465.01
|
| Rate for Payer: Humana Medicare |
$6,465.01
|
| Rate for Payer: IEHP Medi-Cal |
$509.93
|
| Rate for Payer: IEHP Medicare Advantage |
$6,465.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12,283.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,628.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,145.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,145.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,111.51
|
| Rate for Payer: TriValley Medical Group Senior |
$6,465.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: Vantage Medical Group Senior |
$6,465.01
|
|
|
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type)
|
Facility
OP
|
$12,283.52
|
|
|
Service Code
|
CPT 52356
|
| Min. Negotiated Rate |
$552.33 |
| Max. Negotiated Rate |
$12,283.52 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,465.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,111.51
|
| Rate for Payer: Dignity Health Senior |
$6,465.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,465.01
|
| Rate for Payer: Humana Medicare |
$6,465.01
|
| Rate for Payer: IEHP Medi-Cal |
$552.33
|
| Rate for Payer: IEHP Medicare Advantage |
$6,465.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12,283.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,628.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,145.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,145.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,111.51
|
| Rate for Payer: TriValley Medical Group Senior |
$6,465.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: Vantage Medical Group Senior |
$6,465.01
|
|
|
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included)
|
Facility
OP
|
$12,283.52
|
|
|
Service Code
|
CPT 52353
|
| Min. Negotiated Rate |
$552.91 |
| Max. Negotiated Rate |
$12,283.52 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,465.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,111.51
|
| Rate for Payer: Dignity Health Senior |
$6,465.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,465.01
|
| Rate for Payer: Humana Medicare |
$6,465.01
|
| Rate for Payer: IEHP Medi-Cal |
$552.91
|
| Rate for Payer: IEHP Medicare Advantage |
$6,465.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12,283.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,628.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,145.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,145.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,111.51
|
| Rate for Payer: TriValley Medical Group Senior |
$6,465.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: Vantage Medical Group Senior |
$6,465.01
|
|
|
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 52352
|
| Min. Negotiated Rate |
$477.98 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,791.29
|
| Rate for Payer: Dignity Health Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,355.72
|
| Rate for Payer: Humana Medicare |
$4,355.72
|
| Rate for Payer: IEHP Medi-Cal |
$477.98
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,275.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,139.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,488.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,488.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,791.29
|
| Rate for Payer: TriValley Medical Group Senior |
$4,355.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION [120408]
|
Facility
IP
|
$1.52
|
|
|
Service Code
|
CPT J9100
|
| Hospital Charge Code |
NDG120408
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.51
|
|
|
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION [120408]
|
Facility
OP
|
$1.52
|
|
|
Service Code
|
CPT J9100
|
| Hospital Charge Code |
NDG120408
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$13.85 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.85
|
| Rate for Payer: Blue Shield of California Commercial |
$1.04
|
| Rate for Payer: Blue Shield of California EPN |
$1.04
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.29
|
| Rate for Payer: Dignity Health Senior |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: IEHP Medi-Cal |
$8.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Vantage Medical Group Senior |
$1.29
|
|
|
CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION [20156]
|
Facility
OP
|
$1.25
|
|
|
Service Code
|
CPT J9100
|
| Hospital Charge Code |
NDG20156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$13.85 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.85
|
| Rate for Payer: Blue Shield of California Commercial |
$1.04
|
| Rate for Payer: Blue Shield of California Commercial |
$1.04
|
| Rate for Payer: Blue Shield of California EPN |
$1.04
|
| Rate for Payer: Blue Shield of California EPN |
$1.04
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.04
|
| Rate for Payer: Dignity Health Senior |
$1.04
|
| Rate for Payer: Dignity Health Senior |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: IEHP Medi-Cal |
$8.47
|
| Rate for Payer: IEHP Medi-Cal |
$8.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1.04
|
| Rate for Payer: Vantage Medical Group Senior |
$1.06
|
|
|
CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION [20156]
|
Facility
IP
|
$1.25
|
|
|
Service Code
|
CPT J9100
|
| Hospital Charge Code |
NDG20156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.86
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.42
|
|
|
CYTOMEGALOVIRUS IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION [14634]
|
Facility
IP
|
$35.55
|
|
|
Service Code
|
CPT J0850
|
| Hospital Charge Code |
1758636
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.43 |
| Max. Negotiated Rate |
$26.66 |
| Rate for Payer: Adventist Health Commercial |
$7.11
|
| Rate for Payer: Adventist Health Commercial |
$8.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.96
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cash Price |
$18.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.54
|
| Rate for Payer: Heritage Provider Network Senior |
$24.07
|
| Rate for Payer: Heritage Provider Network Senior |
$28.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.54
|
| Rate for Payer: Multiplan Commercial |
$26.66
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.88
|
|
|
CYTOMEGALOVIRUS IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION [14634]
|
Facility
OP
|
$42.16
|
|
|
Service Code
|
CPT J0850
|
| Hospital Charge Code |
1758636
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.63 |
| Max. Negotiated Rate |
$4,441.26 |
| Rate for Payer: Adventist Health Commercial |
$8.43
|
| Rate for Payer: Adventist Health Commercial |
$7.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4,441.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4,441.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,259.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,259.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,988.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,988.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,988.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,988.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,441.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,441.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1,791.99
|
| Rate for Payer: Blue Shield of California Commercial |
$1,791.99
|
| Rate for Payer: Blue Shield of California EPN |
$1,791.99
|
| Rate for Payer: Blue Shield of California EPN |
$1,791.99
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cash Price |
$18.97
|
| Rate for Payer: Cash Price |
$18.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,711.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,711.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,988.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,988.66
|
| Rate for Payer: Dignity Health Senior |
$1,988.66
|
| Rate for Payer: Dignity Health Senior |
$1,988.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.98
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,807.87
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,807.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.46
|
| Rate for Payer: Heritage Provider Network Senior |
$16.46
|
| Rate for Payer: Heritage Provider Network Senior |
$19.52
|
| Rate for Payer: Humana Medicare |
$1,807.87
|
| Rate for Payer: Humana Medicare |
$1,807.87
|
| Rate for Payer: IEHP Medi-Cal |
$2,827.23
|
| Rate for Payer: IEHP Medi-Cal |
$2,827.23
|
| Rate for Payer: IEHP Medicare Advantage |
$1,807.87
|
| Rate for Payer: IEHP Medicare Advantage |
$1,807.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,434.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,434.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,133.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,133.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,277.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,277.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,277.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,277.92
|
| Rate for Payer: Multiplan Commercial |
$26.66
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,988.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,988.66
|
| Rate for Payer: TriValley Medical Group Senior |
$1,807.87
|
| Rate for Payer: TriValley Medical Group Senior |
$1,807.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,711.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,711.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,988.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,988.66
|
| Rate for Payer: Vantage Medical Group Senior |
$1,807.87
|
| Rate for Payer: Vantage Medical Group Senior |
$1,807.87
|
|
|
DABIGATRAN ETEXILATE 110 MG CAPSULE [212609]
|
Facility
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0108-54
|
| Hospital Charge Code |
ERX212609
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.73
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Senior |
$2.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
|
|
DABIGATRAN ETEXILATE 110 MG CAPSULE [212609]
|
Facility
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0108-54
|
| Hospital Charge Code |
ERX212609
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Blue Shield of California Commercial |
$2.47
|
| Rate for Payer: Blue Shield of California EPN |
$2.33
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: Dignity Health Senior |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Senior |
$2.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-82
|
| Hospital Charge Code |
1712463
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.73
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Senior |
$2.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-55
|
| Hospital Charge Code |
1712463
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.73
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Senior |
$2.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-55
|
| Hospital Charge Code |
1712463
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Blue Shield of California Commercial |
$2.47
|
| Rate for Payer: Blue Shield of California EPN |
$2.33
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: Dignity Health Senior |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Senior |
$2.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-82
|
| Hospital Charge Code |
1712463
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Blue Shield of California Commercial |
$2.47
|
| Rate for Payer: Blue Shield of California EPN |
$2.33
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: Dignity Health Senior |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Senior |
$2.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0355-56
|
| Hospital Charge Code |
1712462
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.73
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Senior |
$2.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
|
