|
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [105902]
|
Facility
|
OP
|
$26.82
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
1721093
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$30.75 |
| Rate for Payer: Adventist Health Commercial |
$5.36
|
| Rate for Payer: Adventist Health Commercial |
$3.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$12.07
|
| Rate for Payer: Cash Price |
$12.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.80
|
| Rate for Payer: Dignity Health Senior |
$22.80
|
| Rate for Payer: Dignity Health Senior |
$15.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.33
|
| Rate for Payer: Heritage Provider Network Senior |
$8.33
|
| Rate for Payer: Heritage Provider Network Senior |
$12.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$20.12
|
| Rate for Payer: Multiplan Commercial |
$13.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.73
|
| Rate for Payer: TriValley Medical Group Senior |
$7.20
|
| Rate for Payer: TriValley Medical Group Senior |
$10.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.80
|
| Rate for Payer: Vantage Medical Group Senior |
$22.80
|
| Rate for Payer: Vantage Medical Group Senior |
$15.30
|
|
|
ENTACAPONE 200 MG TABLET [26547]
|
Facility
|
IP
|
$4.94
|
|
|
Service Code
|
NDC 60687-188-11
|
| Hospital Charge Code |
1711797
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$3.70 |
| Rate for Payer: Adventist Health Commercial |
$0.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.39
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.34
|
| Rate for Payer: Heritage Provider Network Senior |
$3.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$3.70
|
|
|
ENTACAPONE 200 MG TABLET [26547]
|
Facility
|
IP
|
$4.94
|
|
|
Service Code
|
NDC 60687-188-21
|
| Hospital Charge Code |
1711797
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$3.70 |
| Rate for Payer: Adventist Health Commercial |
$0.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.39
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.34
|
| Rate for Payer: Heritage Provider Network Senior |
$3.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$3.70
|
|
|
ENTACAPONE 200 MG TABLET [26547]
|
Facility
|
OP
|
$4.94
|
|
|
Service Code
|
NDC 60687-188-21
|
| Hospital Charge Code |
1711797
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Adventist Health Commercial |
$0.99
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.70
|
| Rate for Payer: Blue Shield of California Commercial |
$3.07
|
| Rate for Payer: Blue Shield of California EPN |
$2.90
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.20
|
| Rate for Payer: Dignity Health Senior |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.06
|
| Rate for Payer: Heritage Provider Network Senior |
$3.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$3.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.98
|
| Rate for Payer: TriValley Medical Group Senior |
$1.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.20
|
| Rate for Payer: Vantage Medical Group Senior |
$4.20
|
|
|
ENTACAPONE 200 MG TABLET [26547]
|
Facility
|
OP
|
$4.94
|
|
|
Service Code
|
NDC 60687-188-11
|
| Hospital Charge Code |
1711797
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Adventist Health Commercial |
$0.99
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.70
|
| Rate for Payer: Blue Shield of California Commercial |
$3.07
|
| Rate for Payer: Blue Shield of California EPN |
$2.90
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.20
|
| Rate for Payer: Dignity Health Senior |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.06
|
| Rate for Payer: Heritage Provider Network Senior |
$3.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$3.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.98
|
| Rate for Payer: TriValley Medical Group Senior |
$1.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.20
|
| Rate for Payer: Vantage Medical Group Senior |
$4.20
|
|
|
ENTECAVIR 0.05 MG/ML ORAL SOLUTION [41149]
|
Facility
|
IP
|
$5.49
|
|
|
Service Code
|
NDC 0003-1614-12
|
| Hospital Charge Code |
1715226
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.77
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.72
|
| Rate for Payer: Heritage Provider Network Senior |
$3.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.37
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
|
|
ENTECAVIR 0.05 MG/ML ORAL SOLUTION [41149]
|
Facility
|
OP
|
$5.49
|
|
|
Service Code
|
NDC 0003-1614-12
|
| Hospital Charge Code |
1715226
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.12
|
| Rate for Payer: Blue Shield of California Commercial |
$3.41
|
| Rate for Payer: Blue Shield of California EPN |
$3.22
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.67
|
| Rate for Payer: Dignity Health Senior |
$4.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.40
|
| Rate for Payer: Heritage Provider Network Senior |
$3.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.37
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.20
|
| Rate for Payer: TriValley Medical Group Senior |
$2.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.67
|
| Rate for Payer: Vantage Medical Group Senior |
$4.67
|
|
|
ENTECAVIR 0.5 MG TABLET [41147]
|
Facility
|
OP
|
$3.14
|
|
|
Service Code
|
NDC 42806-658-30
|
| Hospital Charge Code |
1711886
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.67 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.95
|
| Rate for Payer: Blue Shield of California EPN |
$1.84
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.67
|
| Rate for Payer: Dignity Health Senior |
$2.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.26
|
| Rate for Payer: TriValley Medical Group Senior |
$1.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Vantage Medical Group Senior |
$2.67
|
|
|
ENTECAVIR 0.5 MG TABLET [41147]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 31722-833-30
|
| Hospital Charge Code |
1711886
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.36
|
| Rate for Payer: Dignity Health Senior |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.99
|
| Rate for Payer: Heritage Provider Network Senior |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.64
|
| Rate for Payer: TriValley Medical Group Senior |
$0.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1.36
|
|
|
ENTECAVIR 0.5 MG TABLET [41147]
|
Facility
|
IP
|
$3.14
|
|
|
Service Code
|
NDC 42806-658-30
|
| Hospital Charge Code |
1711886
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.16
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Senior |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
|
|
ENTECAVIR 0.5 MG TABLET [41147]
|
Facility
|
IP
|
$2.56
|
|
|
Service Code
|
NDC 69097-426-02
|
| Hospital Charge Code |
1711886
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.76
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Senior |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
|
|
ENTECAVIR 0.5 MG TABLET [41147]
|
Facility
|
OP
|
$2.56
|
|
|
Service Code
|
NDC 69097-426-02
|
| Hospital Charge Code |
1711886
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.92
|
| Rate for Payer: Blue Shield of California Commercial |
$1.59
|
| Rate for Payer: Blue Shield of California EPN |
$1.50
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.18
|
| Rate for Payer: Dignity Health Senior |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.02
|
| Rate for Payer: TriValley Medical Group Senior |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Vantage Medical Group Senior |
$2.18
|
|
|
ENTECAVIR 0.5 MG TABLET [41147]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 31722-833-30
|
| Hospital Charge Code |
1711886
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.10
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
Enterolysis (freeing of intestinal adhesion) (separate procedure)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 44005
|
| Min. Negotiated Rate |
$953.66 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$953.66
|
|
|
ENTRECTINIB 100 MG CAPSULE [225690]
|
Facility
|
IP
|
$254.51
|
|
|
Service Code
|
NDC 50242-091-30
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.07 |
| Max. Negotiated Rate |
$190.88 |
| Rate for Payer: Adventist Health Commercial |
$50.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$174.85
|
| Rate for Payer: Cash Price |
$114.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$117.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$172.30
|
| Rate for Payer: Heritage Provider Network Senior |
$172.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.63
|
| Rate for Payer: Multiplan Commercial |
$190.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$92.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$85.03
|
|
|
ENTRECTINIB 100 MG CAPSULE [225690]
|
Facility
|
OP
|
$254.51
|
|
|
Service Code
|
NDC 50242-091-30
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.07 |
| Max. Negotiated Rate |
$216.33 |
| Rate for Payer: Adventist Health Commercial |
$50.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$136.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$174.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$216.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$139.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$190.88
|
| Rate for Payer: Blue Shield of California Commercial |
$158.05
|
| Rate for Payer: Blue Shield of California EPN |
$149.40
|
| Rate for Payer: Cash Price |
$114.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$117.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$216.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$216.33
|
| Rate for Payer: Dignity Health Senior |
$216.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$117.84
|
| Rate for Payer: Heritage Provider Network Senior |
$117.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$122.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.63
|
| Rate for Payer: Multiplan Commercial |
$190.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$101.80
|
| Rate for Payer: TriValley Medical Group Senior |
$101.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$92.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$85.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$216.33
|
| Rate for Payer: Vantage Medical Group Senior |
$216.33
|
|
|
ENTRECTINIB 200 MG CAPSULE [225691]
|
Facility
|
OP
|
$254.51
|
|
|
Service Code
|
NDC 50242-094-90
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.07 |
| Max. Negotiated Rate |
$216.33 |
| Rate for Payer: Adventist Health Commercial |
$50.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$136.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$174.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$216.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$139.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$190.88
|
| Rate for Payer: Blue Shield of California Commercial |
$158.05
|
| Rate for Payer: Blue Shield of California EPN |
$149.40
|
| Rate for Payer: Cash Price |
$114.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$117.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$216.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$216.33
|
| Rate for Payer: Dignity Health Senior |
$216.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$117.84
|
| Rate for Payer: Heritage Provider Network Senior |
$117.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$122.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.63
|
| Rate for Payer: Multiplan Commercial |
$190.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$101.80
|
| Rate for Payer: TriValley Medical Group Senior |
$101.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$92.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$85.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$216.33
|
| Rate for Payer: Vantage Medical Group Senior |
$216.33
|
|
|
ENTRECTINIB 200 MG CAPSULE [225691]
|
Facility
|
IP
|
$254.51
|
|
|
Service Code
|
NDC 50242-094-90
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.07 |
| Max. Negotiated Rate |
$190.88 |
| Rate for Payer: Adventist Health Commercial |
$50.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$174.85
|
| Rate for Payer: Cash Price |
$114.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$117.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$172.30
|
| Rate for Payer: Heritage Provider Network Senior |
$172.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.63
|
| Rate for Payer: Multiplan Commercial |
$190.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$92.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$85.03
|
|
|
Enucleation of eye; with implant, muscles attached to implant
|
Facility
|
OP
|
$9,178.50
|
|
|
Service Code
|
CPT 65105
|
| Min. Negotiated Rate |
$789.30 |
| Max. Negotiated Rate |
$9,178.50 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,246.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,313.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,830.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,246.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,313.87
|
| Rate for Payer: Dignity Health Senior |
$4,830.79
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,830.79
|
| Rate for Payer: Humana Medicare |
$4,830.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$789.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,830.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,178.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,700.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,086.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,086.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,313.87
|
| Rate for Payer: TriValley Medical Group Senior |
$4,830.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,246.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,313.87
|
| Rate for Payer: Vantage Medical Group Senior |
$4,830.79
|
|
|
EPCORITAMAB-BYSP 48 MG/0.8 ML SUBCUTANEOUS SOLUTION [238112]
|
Facility
|
OP
|
$22,838.34
|
|
|
Service Code
|
CPT C9155
|
| Hospital Charge Code |
ERX238112
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,133.74 |
| Max. Negotiated Rate |
$19,412.59 |
| Rate for Payer: Adventist Health Commercial |
$4,567.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12,207.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15,689.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19,412.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12,561.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17,128.76
|
| Rate for Payer: Blue Shield of California Commercial |
$14,182.61
|
| Rate for Payer: Blue Shield of California EPN |
$13,406.11
|
| Rate for Payer: Cash Price |
$10,277.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10,505.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19,412.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$19,412.59
|
| Rate for Payer: Dignity Health Senior |
$19,412.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$14,616.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$10,574.15
|
| Rate for Payer: Heritage Provider Network Senior |
$10,574.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11,008.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,133.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,709.58
|
| Rate for Payer: Multiplan Commercial |
$17,128.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,135.34
|
| Rate for Payer: TriValley Medical Group Senior |
$9,135.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8,326.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7,630.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19,412.59
|
| Rate for Payer: Vantage Medical Group Senior |
$19,412.59
|
|
|
EPCORITAMAB-BYSP 48 MG/0.8 ML SUBCUTANEOUS SOLUTION [238112]
|
Facility
|
IP
|
$22,838.34
|
|
|
Service Code
|
CPT C9155
|
| Hospital Charge Code |
ERX238112
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,133.74 |
| Max. Negotiated Rate |
$17,128.76 |
| Rate for Payer: Adventist Health Commercial |
$4,567.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15,689.94
|
| Rate for Payer: Cash Price |
$10,277.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10,505.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,332.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$15,461.56
|
| Rate for Payer: Heritage Provider Network Senior |
$15,461.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,133.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,709.58
|
| Rate for Payer: Multiplan Commercial |
$17,128.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8,326.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7,630.29
|
|
|
EPCORITAMAB-BYSP 4 MG/0.8 ML SUBCUTANEOUS SOLUTION (MUST DILUTE) [238113]
|
Facility
|
OP
|
$1,903.20
|
|
|
Service Code
|
CPT C9155
|
| Hospital Charge Code |
ERX238113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$344.48 |
| Max. Negotiated Rate |
$1,617.72 |
| Rate for Payer: Adventist Health Commercial |
$380.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,017.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,307.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,617.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,046.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,427.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1,181.89
|
| Rate for Payer: Blue Shield of California EPN |
$1,117.18
|
| Rate for Payer: Cash Price |
$856.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$875.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,617.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,617.72
|
| Rate for Payer: Dignity Health Senior |
$1,617.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,218.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$881.18
|
| Rate for Payer: Heritage Provider Network Senior |
$881.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$917.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$344.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$475.80
|
| Rate for Payer: Multiplan Commercial |
$1,427.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$761.28
|
| Rate for Payer: TriValley Medical Group Senior |
$761.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$693.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$635.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,617.72
|
| Rate for Payer: Vantage Medical Group Senior |
$1,617.72
|
|
|
EPCORITAMAB-BYSP 4 MG/0.8 ML SUBCUTANEOUS SOLUTION (MUST DILUTE) [238113]
|
Facility
|
IP
|
$1,903.20
|
|
|
Service Code
|
CPT C9155
|
| Hospital Charge Code |
ERX238113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$344.48 |
| Max. Negotiated Rate |
$1,427.40 |
| Rate for Payer: Adventist Health Commercial |
$380.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,307.50
|
| Rate for Payer: Cash Price |
$856.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$875.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,027.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,288.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1,288.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$344.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$475.80
|
| Rate for Payer: Multiplan Commercial |
$1,427.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$693.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$635.86
|
|
|
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE [120232]
|
Facility
|
IP
|
$4.76
|
|
|
Service Code
|
NDC 70092-1478-44
|
| Hospital Charge Code |
1722051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.27
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.57
|
|
|
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE [120232]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 70004-604-09
|
| Hospital Charge Code |
1722051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.06
|
| Rate for Payer: Heritage Provider Network Senior |
$4.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
