|
ARIPIPRAZOLE 10 MG TABLET [34369]
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 50268-089-15
|
| Hospital Charge Code |
1711827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| 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 Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
ARIPIPRAZOLE 10 MG TABLET [34369]
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 50268-089-11
|
| Hospital Charge Code |
1711827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| 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 Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
ARIPIPRAZOLE 10 MG TABLET [34369]
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 50268-089-11
|
| Hospital Charge Code |
1711827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Senior |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Senior |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
|
|
ARIPIPRAZOLE 10 MG TABLET [34369]
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 50268-089-15
|
| Hospital Charge Code |
1711827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Senior |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Senior |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
|
|
ARIPIPRAZOLE 15 MG TABLET [34370]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 62332-100-30
|
| Hospital Charge Code |
1711828
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Senior |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
ARIPIPRAZOLE 15 MG TABLET [34370]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 62332-100-30
|
| Hospital Charge Code |
1711828
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
ARIPIPRAZOLE 1 MG/ML ORAL SOLUTION [40446]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 66689-735-05
|
| Hospital Charge Code |
1715222
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Senior |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
ARIPIPRAZOLE 1 MG/ML ORAL SOLUTION [40446]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 66689-735-05
|
| Hospital Charge Code |
1715222
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
ARIPIPRAZOLE 2 MG TABLET [70306]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 62332-097-30
|
| Hospital Charge Code |
1712401
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Senior |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
ARIPIPRAZOLE 2 MG TABLET [70306]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 62332-097-30
|
| Hospital Charge Code |
1712401
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
ARIPIPRAZOLE 2 MG TABLET [70306]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 67877-430-03
|
| Hospital Charge Code |
1712401
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
ARIPIPRAZOLE 2 MG TABLET [70306]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 67877-430-03
|
| Hospital Charge Code |
1712401
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
ARIPIPRAZOLE 5 MG TABLET [36438]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 62332-098-30
|
| Hospital Charge Code |
1712297
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Senior |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
ARIPIPRAZOLE 5 MG TABLET [36438]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 62332-098-30
|
| Hospital Charge Code |
1712297
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION [220455]
|
Facility
|
IP
|
$213.28
|
|
|
Service Code
|
CPT J9017
|
| Hospital Charge Code |
NDG220455
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.60 |
| Max. Negotiated Rate |
$159.96 |
| Rate for Payer: Adventist Health Commercial |
$42.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$146.52
|
| Rate for Payer: Cash Price |
$95.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$98.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$115.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$144.39
|
| Rate for Payer: Heritage Provider Network Senior |
$144.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.32
|
| Rate for Payer: Multiplan Commercial |
$159.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$77.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.26
|
|
|
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION [220455]
|
Facility
|
OP
|
$213.28
|
|
|
Service Code
|
CPT J9017
|
| Hospital Charge Code |
NDG220455
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.78 |
| Max. Negotiated Rate |
$159.96 |
| Rate for Payer: Adventist Health Commercial |
$42.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$31.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$146.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$58.87
|
| Rate for Payer: Blue Shield of California Commercial |
$42.47
|
| Rate for Payer: Blue Shield of California EPN |
$42.47
|
| Rate for Payer: Cash Price |
$95.98
|
| Rate for Payer: Cash Price |
$95.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$98.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.36
|
| Rate for Payer: Dignity Health Senior |
$17.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$136.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$15.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$98.75
|
| Rate for Payer: Heritage Provider Network Senior |
$98.75
|
| Rate for Payer: Humana Medicare |
$15.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$31.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$29.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19.89
|
| Rate for Payer: Multiplan Commercial |
$159.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$85.31
|
| Rate for Payer: TriValley Medical Group Senior |
$85.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$77.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.36
|
| Rate for Payer: Vantage Medical Group Senior |
$15.78
|
|
|
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET [96948]
|
Facility
|
OP
|
$6.74
|
|
|
Service Code
|
NDC 0078-0568-45
|
| Hospital Charge Code |
1712541
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$5.73 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.06
|
| Rate for Payer: Blue Shield of California Commercial |
$4.19
|
| Rate for Payer: Blue Shield of California EPN |
$3.96
|
| Rate for Payer: Cash Price |
$3.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.73
|
| Rate for Payer: Dignity Health Senior |
$5.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.17
|
| Rate for Payer: Heritage Provider Network Senior |
$4.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$5.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Senior |
$2.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.73
|
| Rate for Payer: Vantage Medical Group Senior |
$5.73
|
|
|
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET [96948]
|
Facility
|
IP
|
$6.74
|
|
|
Service Code
|
NDC 0078-0568-45
|
| Hospital Charge Code |
1712541
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$5.06 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.63
|
| Rate for Payer: Cash Price |
$3.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.56
|
| Rate for Payer: Heritage Provider Network Senior |
$4.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$5.06
|
|
|
Arteriovenous anastomosis, open; by upper arm basilic vein transposition
|
Facility
|
OP
|
$13,045.53
|
|
|
Service Code
|
CPT 36819
|
| Min. Negotiated Rate |
$169.59 |
| Max. Negotiated Rate |
$13,045.53 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,299.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,552.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6,866.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,299.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,552.68
|
| Rate for Payer: Dignity Health Senior |
$6,866.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,866.07
|
| Rate for Payer: Humana Medicare |
$6,866.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$169.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6,866.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,045.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,101.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,651.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,651.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,552.68
|
| Rate for Payer: TriValley Medical Group Senior |
$6,866.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,299.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,552.68
|
| Rate for Payer: Vantage Medical Group Senior |
$6,866.07
|
|
|
Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) (separate procedure)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 36821
|
| Min. Negotiated Rate |
$138.23 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,973.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,380.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,982.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,973.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,380.80
|
| Rate for Payer: Dignity Health Senior |
$3,982.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,982.55
|
| Rate for Payer: Humana Medicare |
$3,982.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$138.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,982.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,566.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,699.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,018.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,018.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,380.80
|
| Rate for Payer: TriValley Medical Group Senior |
$3,982.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,973.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,380.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,982.55
|
|
|
ARTESUNATE 110 MG INTRAVENOUS SOLUTION [230847]
|
Facility
|
OP
|
$5,976.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
ERX230847
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,081.66 |
| Max. Negotiated Rate |
$5,079.60 |
| Rate for Payer: Adventist Health Commercial |
$1,195.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,194.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,105.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,079.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,286.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,482.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,711.10
|
| Rate for Payer: Blue Shield of California EPN |
$3,507.91
|
| Rate for Payer: Cash Price |
$2,689.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,748.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,079.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,079.60
|
| Rate for Payer: Dignity Health Senior |
$5,079.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,824.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,766.89
|
| Rate for Payer: Heritage Provider Network Senior |
$2,766.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,880.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,081.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,494.00
|
| Rate for Payer: Multiplan Commercial |
$4,482.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,390.40
|
| Rate for Payer: TriValley Medical Group Senior |
$2,390.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,178.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,996.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,079.60
|
| Rate for Payer: Vantage Medical Group Senior |
$5,079.60
|
|
|
ARTESUNATE 110 MG INTRAVENOUS SOLUTION [230847]
|
Facility
|
IP
|
$5,976.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
ERX230847
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,081.66 |
| Max. Negotiated Rate |
$4,482.00 |
| Rate for Payer: Adventist Health Commercial |
$1,195.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,105.51
|
| Rate for Payer: Cash Price |
$2,689.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,748.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,227.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,045.75
|
| Rate for Payer: Heritage Provider Network Senior |
$4,045.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,081.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,494.00
|
| Rate for Payer: Multiplan Commercial |
$4,482.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,178.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,996.58
|
|
|
Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 20605
|
| Min. Negotiated Rate |
$59.23 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$370.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$555.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$407.07
|
| Rate for Payer: Dignity Health Senior |
$370.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$370.06
|
| Rate for Payer: Humana Medicare |
$370.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$59.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$370.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$703.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$436.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$466.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$466.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$407.07
|
| Rate for Payer: TriValley Medical Group Senior |
$370.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Vantage Medical Group Senior |
$370.06
|
|
|
Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 20610
|
| Min. Negotiated Rate |
$71.43 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$370.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$555.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$407.07
|
| Rate for Payer: Dignity Health Senior |
$370.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$370.06
|
| Rate for Payer: Humana Medicare |
$370.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$71.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$370.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$703.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$436.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$466.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$466.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$407.07
|
| Rate for Payer: TriValley Medical Group Senior |
$370.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Vantage Medical Group Senior |
$370.06
|
|
|
Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 20600
|
| Min. Negotiated Rate |
$50.53 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$370.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$555.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$407.07
|
| Rate for Payer: Dignity Health Senior |
$370.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$370.06
|
| Rate for Payer: Humana Medicare |
$370.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$50.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$370.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$703.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$436.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$466.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$466.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$407.07
|
| Rate for Payer: TriValley Medical Group Senior |
$370.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Vantage Medical Group Senior |
$370.06
|
|
