|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [217071]
|
Facility
|
OP
|
$473.79
|
|
|
Service Code
|
NDC 0310-4611-50
|
| Hospital Charge Code |
NDG217071A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.76 |
| Max. Negotiated Rate |
$402.72 |
| Rate for Payer: Adventist Health Commercial |
$94.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$253.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$325.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$402.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$260.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$355.34
|
| Rate for Payer: Blue Shield of California Commercial |
$294.22
|
| Rate for Payer: Blue Shield of California EPN |
$278.11
|
| Rate for Payer: Cash Price |
$213.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$217.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$402.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$402.72
|
| Rate for Payer: Dignity Health Senior |
$402.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$303.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$219.36
|
| Rate for Payer: Heritage Provider Network Senior |
$219.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$228.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$85.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$118.45
|
| Rate for Payer: Multiplan Commercial |
$355.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$189.52
|
| Rate for Payer: TriValley Medical Group Senior |
$189.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$172.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$158.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$402.72
|
| Rate for Payer: Vantage Medical Group Senior |
$402.72
|
|
|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [217071]
|
Facility
|
IP
|
$473.79
|
|
|
Service Code
|
NDC 0310-4500-12
|
| Hospital Charge Code |
NDG217071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.76 |
| Max. Negotiated Rate |
$355.34 |
| Rate for Payer: Adventist Health Commercial |
$94.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$325.49
|
| Rate for Payer: Cash Price |
$213.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$217.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$255.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$320.76
|
| Rate for Payer: Heritage Provider Network Senior |
$320.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$85.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$118.45
|
| Rate for Payer: Multiplan Commercial |
$355.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$172.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$158.29
|
|
|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [217071]
|
Facility
|
IP
|
$473.79
|
|
|
Service Code
|
NDC 0310-4611-50
|
| Hospital Charge Code |
NDG217071A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.76 |
| Max. Negotiated Rate |
$355.34 |
| Rate for Payer: Adventist Health Commercial |
$94.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$325.49
|
| Rate for Payer: Cash Price |
$213.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$217.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$255.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$320.76
|
| Rate for Payer: Heritage Provider Network Senior |
$320.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$85.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$118.45
|
| Rate for Payer: Multiplan Commercial |
$355.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$172.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$158.29
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 0173-0712-15
|
| Hospital Charge Code |
1710969
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.25 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.45
|
| Rate for Payer: Heritage Provider Network Senior |
$7.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.25
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 0173-0712-04
|
| Hospital Charge Code |
1710969
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.25 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.45
|
| Rate for Payer: Heritage Provider Network Senior |
$7.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.25
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 0173-0712-15
|
| Hospital Charge Code |
1710969
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$9.35 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.25
|
| Rate for Payer: Blue Shield of California Commercial |
$6.83
|
| Rate for Payer: Blue Shield of California EPN |
$6.46
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.35
|
| Rate for Payer: Dignity Health Senior |
$9.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.81
|
| Rate for Payer: Heritage Provider Network Senior |
$6.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.40
|
| Rate for Payer: TriValley Medical Group Senior |
$4.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.35
|
| Rate for Payer: Vantage Medical Group Senior |
$9.35
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 42806-549-30
|
| Hospital Charge Code |
1710969
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| 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 Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 42806-549-30
|
| Hospital Charge Code |
1710969
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Senior |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Senior |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 0173-0712-04
|
| Hospital Charge Code |
1710969
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$9.35 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.25
|
| Rate for Payer: Blue Shield of California Commercial |
$6.83
|
| Rate for Payer: Blue Shield of California EPN |
$6.46
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.35
|
| Rate for Payer: Dignity Health Senior |
$9.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.81
|
| Rate for Payer: Heritage Provider Network Senior |
$6.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.40
|
| Rate for Payer: TriValley Medical Group Senior |
$4.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.35
|
| Rate for Payer: Vantage Medical Group Senior |
$9.35
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
|
IP
|
$16,755.04
|
|
|
Service Code
|
APR-DRG 1104
|
| Min. Negotiated Rate |
$16,755.04 |
| Max. Negotiated Rate |
$16,755.04 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16,755.04
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
|
IP
|
$10,289.21
|
|
|
Service Code
|
APR-DRG 1103
|
| Min. Negotiated Rate |
$10,289.21 |
| Max. Negotiated Rate |
$10,289.21 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,289.21
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
|
IP
|
$7,102.57
|
|
|
Service Code
|
APR-DRG 1102
|
| Min. Negotiated Rate |
$7,102.57 |
| Max. Negotiated Rate |
$7,102.57 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,102.57
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
|
IP
|
$6,209.15
|
|
|
Service Code
|
APR-DRG 1101
|
| Min. Negotiated Rate |
$6,209.15 |
| Max. Negotiated Rate |
$6,209.15 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,209.15
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$11,342.81
|
|
|
Service Code
|
APR-DRG 7593
|
| Min. Negotiated Rate |
$11,342.81 |
| Max. Negotiated Rate |
$11,342.81 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,342.81
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$46,859.60
|
|
|
Service Code
|
APR-DRG 7594
|
| Min. Negotiated Rate |
$46,859.60 |
| Max. Negotiated Rate |
$46,859.60 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$46,859.60
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$5,239.12
|
|
|
Service Code
|
APR-DRG 7591
|
| Min. Negotiated Rate |
$5,239.12 |
| Max. Negotiated Rate |
$5,239.12 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,239.12
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$8,198.94
|
|
|
Service Code
|
APR-DRG 7592
|
| Min. Negotiated Rate |
$8,198.94 |
| Max. Negotiated Rate |
$8,198.94 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,198.94
|
|
|
ECONAZOLE 1 % TOPICAL CREAM [9915]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 51672-1303-1
|
| Hospital Charge Code |
NDG9915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California EPN |
$2.35
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: Dignity Health Senior |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.48
|
| Rate for Payer: Heritage Provider Network Senior |
$2.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.60
|
| Rate for Payer: TriValley Medical Group Senior |
$1.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
|
|
ECONAZOLE 1 % TOPICAL CREAM [9915]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 51672-1303-1
|
| Hospital Charge Code |
NDG9915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.75
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
|
|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]
|
Facility
|
IP
|
$260.92
|
|
|
Service Code
|
CPT J1300
|
| Hospital Charge Code |
NDG81696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$195.69 |
| Rate for Payer: Adventist Health Commercial |
$52.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$179.25
|
| Rate for Payer: Cash Price |
$117.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$120.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$176.64
|
| Rate for Payer: Heritage Provider Network Senior |
$176.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.23
|
| Rate for Payer: Multiplan Commercial |
$195.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$95.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$87.17
|
|
|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]
|
Facility
|
OP
|
$260.92
|
|
|
Service Code
|
CPT J1300
|
| Hospital Charge Code |
NDG81696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$554.42 |
| Rate for Payer: Adventist Health Commercial |
$52.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$554.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$179.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$282.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$248.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$248.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$370.39
|
| Rate for Payer: Blue Shield of California Commercial |
$221.78
|
| Rate for Payer: Blue Shield of California EPN |
$221.78
|
| Rate for Payer: Cash Price |
$117.41
|
| Rate for Payer: Cash Price |
$117.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$120.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$338.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$248.25
|
| Rate for Payer: Dignity Health Senior |
$248.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$166.99
|
| Rate for Payer: EPIC Health Plan Medicare |
$225.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$120.81
|
| Rate for Payer: Heritage Provider Network Senior |
$120.81
|
| Rate for Payer: Humana Medicare |
$225.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$359.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$225.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$428.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$266.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$284.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$284.36
|
| Rate for Payer: Multiplan Commercial |
$195.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$104.37
|
| Rate for Payer: TriValley Medical Group Senior |
$104.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$95.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$87.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$338.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$248.25
|
| Rate for Payer: Vantage Medical Group Senior |
$225.68
|
|
|
EDETATE CALCIUM DISODIUM 200 MG/ML INJECTION SOLUTION [9916]
|
Facility
|
OP
|
$1,292.51
|
|
|
Service Code
|
CPT J0600
|
| Hospital Charge Code |
NDG9916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.21 |
| Max. Negotiated Rate |
$15,733.70 |
| Rate for Payer: Adventist Health Commercial |
$258.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15,733.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$887.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8,065.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,097.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,097.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.21
|
| Rate for Payer: Blue Shield of California Commercial |
$5,493.18
|
| Rate for Payer: Blue Shield of California EPN |
$5,493.18
|
| Rate for Payer: Cash Price |
$581.63
|
| Rate for Payer: Cash Price |
$581.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$594.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,678.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,097.75
|
| Rate for Payer: Dignity Health Senior |
$7,097.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$827.21
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,452.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$598.43
|
| Rate for Payer: Heritage Provider Network Senior |
$598.43
|
| Rate for Payer: Humana Medicare |
$6,452.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6,452.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12,259.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$233.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,613.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$323.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,130.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,130.15
|
| Rate for Payer: Multiplan Commercial |
$969.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$517.00
|
| Rate for Payer: TriValley Medical Group Senior |
$517.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$471.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$431.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,678.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,097.75
|
| Rate for Payer: Vantage Medical Group Senior |
$6,452.50
|
|
|
EDETATE CALCIUM DISODIUM 200 MG/ML INJECTION SOLUTION [9916]
|
Facility
|
IP
|
$1,292.51
|
|
|
Service Code
|
CPT J0600
|
| Hospital Charge Code |
NDG9916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$233.94 |
| Max. Negotiated Rate |
$969.38 |
| Rate for Payer: Adventist Health Commercial |
$258.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$887.95
|
| Rate for Payer: Cash Price |
$581.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$594.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$697.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$875.03
|
| Rate for Payer: Heritage Provider Network Senior |
$875.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$233.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$323.13
|
| Rate for Payer: Multiplan Commercial |
$969.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$471.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$431.83
|
|
|
EDETATE DISODIUM 3 % EYE DROPS [222529]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG222529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.61
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.31
|
| Rate for Payer: Heritage Provider Network Senior |
$20.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.02
|
|
|
EDETATE DISODIUM 3 % EYE DROPS [222529]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG222529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.50
|
| Rate for Payer: Blue Shield of California Commercial |
$18.63
|
| Rate for Payer: Blue Shield of California EPN |
$17.61
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.50
|
| Rate for Payer: Dignity Health Senior |
$25.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.89
|
| Rate for Payer: Heritage Provider Network Senior |
$13.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.00
|
| Rate for Payer: TriValley Medical Group Senior |
$12.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.50
|
| Rate for Payer: Vantage Medical Group Senior |
$25.50
|
|
