|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
IP
|
$15.29
|
|
|
Service Code
|
NDC 0065-0396-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$11.47 |
| Rate for Payer: Adventist Health Commercial |
$3.06
|
| Rate for Payer: Cash Price |
$8.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.35
|
| Rate for Payer: Heritage Provider Network Senior |
$10.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.82
|
| Rate for Payer: Multiplan Commercial |
$11.47
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 61314-396-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
NDC 61314-396-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Blue Shield of California Commercial |
$1.37
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Senior |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Senior |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.90
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
OP
|
$15.29
|
|
|
Service Code
|
NDC 0065-0396-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Adventist Health Commercial |
$3.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.47
|
| Rate for Payer: Blue Shield of California Commercial |
$9.33
|
| Rate for Payer: Blue Shield of California EPN |
$7.46
|
| Rate for Payer: Cash Price |
$8.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.00
|
| Rate for Payer: Dignity Health Senior |
$13.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.46
|
| Rate for Payer: Heritage Provider Network Senior |
$9.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.70
|
| Rate for Payer: Multiplan Commercial |
$11.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.12
|
| Rate for Payer: TriValley Medical Group Senior |
$6.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.00
|
| Rate for Payer: Vantage Medical Group Senior |
$13.00
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
OP
|
$7.17
|
|
|
Service Code
|
NDC 61314-396-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$6.09 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.38
|
| Rate for Payer: Blue Shield of California Commercial |
$4.37
|
| Rate for Payer: Blue Shield of California EPN |
$3.50
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.09
|
| Rate for Payer: Dignity Health Senior |
$6.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.44
|
| Rate for Payer: Heritage Provider Network Senior |
$4.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.02
|
| Rate for Payer: Multiplan Commercial |
$5.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.87
|
| Rate for Payer: TriValley Medical Group Senior |
$2.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.09
|
| Rate for Payer: Vantage Medical Group Senior |
$6.09
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
IP
|
$7.17
|
|
|
Service Code
|
NDC 61314-396-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$5.38 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.85
|
| Rate for Payer: Heritage Provider Network Senior |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$5.38
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS >2 ML [4082025]
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
NDC 61314-396-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Blue Shield of California Commercial |
$1.37
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Senior |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Senior |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.90
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS >2 ML [4082025]
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 61314-396-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
|
|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS [9701]
|
Facility
|
OP
|
$22.21
|
|
|
Service Code
|
NDC 0065-0359-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$18.88 |
| Rate for Payer: Adventist Health Commercial |
$4.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.66
|
| Rate for Payer: Blue Shield of California Commercial |
$13.55
|
| Rate for Payer: Blue Shield of California EPN |
$10.84
|
| Rate for Payer: Cash Price |
$12.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.88
|
| Rate for Payer: Dignity Health Senior |
$18.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.75
|
| Rate for Payer: Heritage Provider Network Senior |
$13.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.55
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.88
|
| Rate for Payer: TriValley Medical Group Senior |
$8.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.88
|
| Rate for Payer: Vantage Medical Group Senior |
$18.88
|
|
|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS [9701]
|
Facility
|
IP
|
$22.21
|
|
|
Service Code
|
NDC 0065-0359-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$16.66 |
| Rate for Payer: Adventist Health Commercial |
$4.44
|
| Rate for Payer: Cash Price |
$12.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.04
|
| Rate for Payer: Heritage Provider Network Senior |
$15.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.55
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
|
|
CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]
|
Facility
|
OP
|
$432.00
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$324.00 |
| Rate for Payer: Adventist Health Commercial |
$86.40
|
| Rate for Payer: Adventist Health Commercial |
$60.72
|
| Rate for Payer: Adventist Health Commercial |
$56.64
|
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$230.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$151.37
|
| Rate for Payer: Aetna of CA Gatekeeper |
$162.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$112.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$296.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$144.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$194.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$208.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.79
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.89
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$166.98
|
| Rate for Payer: Cash Price |
$155.76
|
| Rate for Payer: Cash Price |
$166.98
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$155.76
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$198.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$130.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$139.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$194.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$181.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$276.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$134.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.62
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.62
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.62
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$200.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$140.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$131.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$97.23
|
| Rate for Payer: Heritage Provider Network Senior |
$200.02
|
| Rate for Payer: Heritage Provider Network Senior |
$131.12
|
| Rate for Payer: Heritage Provider Network Senior |
$97.23
|
| Rate for Payer: Heritage Provider Network Senior |
$140.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$206.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$100.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$135.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$144.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$212.40
|
| Rate for Payer: Multiplan Commercial |
$157.50
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: Multiplan Commercial |
$227.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$84.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$121.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$172.80
|
| Rate for Payer: TriValley Medical Group Senior |
$84.00
|
| Rate for Payer: TriValley Medical Group Senior |
$113.28
|
| Rate for Payer: TriValley Medical Group Senior |
$172.80
|
| Rate for Payer: TriValley Medical Group Senior |
$121.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$75.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$109.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$102.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$156.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$100.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$143.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$69.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
|
|
CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]
|
Facility
|
OP
|
$672.43
|
|
|
Service Code
|
HCPCS J9074
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.21 |
| Max. Negotiated Rate |
$504.32 |
| Rate for Payer: Adventist Health Commercial |
$134.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$359.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$461.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.35
|
| Rate for Payer: Blue Shield of California Commercial |
$4.47
|
| Rate for Payer: Blue Shield of California EPN |
$4.47
|
| Rate for Payer: Cash Price |
$369.84
|
| Rate for Payer: Cash Price |
$369.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$309.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.63
|
| Rate for Payer: Dignity Health Senior |
$4.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$430.36
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$311.34
|
| Rate for Payer: Heritage Provider Network Senior |
$311.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$320.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$121.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.30
|
| Rate for Payer: Multiplan Commercial |
$504.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$268.97
|
| Rate for Payer: TriValley Medical Group Senior |
$268.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$242.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$222.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4.63
|
|
|
CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]
|
Facility
|
IP
|
$672.43
|
|
|
Service Code
|
HCPCS J9074
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$121.71 |
| Max. Negotiated Rate |
$504.32 |
| Rate for Payer: Adventist Health Commercial |
$134.49
|
| Rate for Payer: Cash Price |
$369.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$309.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$363.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$311.34
|
| Rate for Payer: Heritage Provider Network Senior |
$311.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$121.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.11
|
| Rate for Payer: Multiplan Commercial |
$504.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$242.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$222.64
|
|
|
CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]
|
Facility
|
IP
|
$303.60
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.95 |
| Max. Negotiated Rate |
$227.70 |
| Rate for Payer: Adventist Health Commercial |
$60.72
|
| Rate for Payer: Adventist Health Commercial |
$86.40
|
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Adventist Health Commercial |
$56.64
|
| Rate for Payer: Cash Price |
$155.76
|
| Rate for Payer: Cash Price |
$166.98
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$139.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$198.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$130.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$163.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$233.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$200.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$140.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$131.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$97.23
|
| Rate for Payer: Heritage Provider Network Senior |
$200.02
|
| Rate for Payer: Heritage Provider Network Senior |
$97.23
|
| Rate for Payer: Heritage Provider Network Senior |
$131.12
|
| Rate for Payer: Heritage Provider Network Senior |
$140.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$157.50
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: Multiplan Commercial |
$227.70
|
| Rate for Payer: Multiplan Commercial |
$212.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$109.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$102.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$75.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$156.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$143.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$100.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$69.53
|
|
|
CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION [228986]
|
Facility
|
IP
|
$175.80
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.82 |
| Max. Negotiated Rate |
$131.85 |
| Rate for Payer: Adventist Health Commercial |
$35.16
|
| Rate for Payer: Cash Price |
$96.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$80.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$94.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.40
|
| Rate for Payer: Heritage Provider Network Senior |
$81.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.95
|
| Rate for Payer: Multiplan Commercial |
$131.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$63.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$58.21
|
|
|
CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION [228986]
|
Facility
|
OP
|
$175.80
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$131.85 |
| Rate for Payer: Adventist Health Commercial |
$35.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$93.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$120.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.79
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.89
|
| Rate for Payer: Cash Price |
$96.69
|
| Rate for Payer: Cash Price |
$96.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$80.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.51
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.40
|
| Rate for Payer: Heritage Provider Network Senior |
$81.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$83.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$131.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$70.32
|
| Rate for Payer: TriValley Medical Group Senior |
$70.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$63.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$58.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
|
|
CYCLOPHOSPHAMIDE 25 MG CAPSULE [206105]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
HCPCS J8530
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| 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: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.19
|
|
|
CYCLOPHOSPHAMIDE 25 MG CAPSULE [206105]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J8530
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$7.71 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.71
|
| Rate for Payer: Blue Shield of California Commercial |
$3.03
|
| Rate for Payer: Blue Shield of California Commercial |
$3.03
|
| Rate for Payer: Blue Shield of California EPN |
$3.03
|
| Rate for Payer: Blue Shield of California EPN |
$3.03
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Senior |
$3.06
|
| Rate for Payer: Dignity Health Senior |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Senior |
$1.44
|
| Rate for Payer: TriValley Medical Group Senior |
$2.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION [28922]
|
Facility
|
OP
|
$864.00
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$648.00 |
| Rate for Payer: Adventist Health Commercial |
$172.80
|
| Rate for Payer: Adventist Health Commercial |
$88.80
|
| Rate for Payer: Adventist Health Commercial |
$108.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$461.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$237.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$289.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$593.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$305.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$372.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.79
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.89
|
| Rate for Payer: Cash Price |
$298.32
|
| Rate for Payer: Cash Price |
$298.32
|
| Rate for Payer: Cash Price |
$244.20
|
| Rate for Payer: Cash Price |
$475.20
|
| Rate for Payer: Cash Price |
$244.20
|
| Rate for Payer: Cash Price |
$475.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$249.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$204.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$397.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$347.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$284.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$552.96
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.62
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.62
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$251.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$400.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$205.57
|
| Rate for Payer: Heritage Provider Network Senior |
$251.13
|
| Rate for Payer: Heritage Provider Network Senior |
$400.03
|
| Rate for Payer: Heritage Provider Network Senior |
$205.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$412.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$258.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$211.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$156.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$216.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$406.80
|
| Rate for Payer: Multiplan Commercial |
$333.00
|
| Rate for Payer: Multiplan Commercial |
$648.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$216.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$177.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$345.60
|
| Rate for Payer: TriValley Medical Group Senior |
$177.60
|
| Rate for Payer: TriValley Medical Group Senior |
$216.96
|
| Rate for Payer: TriValley Medical Group Senior |
$345.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$195.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$160.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$312.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$147.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$179.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$286.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
|
|
CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION [28922]
|
Facility
|
IP
|
$542.40
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.17 |
| Max. Negotiated Rate |
$406.80 |
| Rate for Payer: Adventist Health Commercial |
$108.48
|
| Rate for Payer: Adventist Health Commercial |
$88.80
|
| Rate for Payer: Adventist Health Commercial |
$172.80
|
| Rate for Payer: Cash Price |
$298.32
|
| Rate for Payer: Cash Price |
$475.20
|
| Rate for Payer: Cash Price |
$244.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$397.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$249.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$204.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$292.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$239.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$466.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$400.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$205.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$251.13
|
| Rate for Payer: Heritage Provider Network Senior |
$251.13
|
| Rate for Payer: Heritage Provider Network Senior |
$205.57
|
| Rate for Payer: Heritage Provider Network Senior |
$400.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$156.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$216.00
|
| Rate for Payer: Multiplan Commercial |
$648.00
|
| Rate for Payer: Multiplan Commercial |
$333.00
|
| Rate for Payer: Multiplan Commercial |
$406.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$160.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$312.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$195.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$286.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$147.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$179.59
|
|
|
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [38271]
|
Facility
|
IP
|
$216.00
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.10 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Adventist Health Commercial |
$43.20
|
| Rate for Payer: Adventist Health Commercial |
$28.32
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cash Price |
$77.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$99.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$116.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$100.01
|
| Rate for Payer: Heritage Provider Network Senior |
$100.01
|
| Rate for Payer: Heritage Provider Network Senior |
$65.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.40
|
| Rate for Payer: Multiplan Commercial |
$106.20
|
| Rate for Payer: Multiplan Commercial |
$162.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$51.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$78.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$46.88
|
|
|
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [38271]
|
Facility
|
OP
|
$336.23
|
|
|
Service Code
|
HCPCS J9074
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.21 |
| Max. Negotiated Rate |
$252.17 |
| Rate for Payer: Adventist Health Commercial |
$67.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$179.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$230.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.35
|
| Rate for Payer: Blue Shield of California Commercial |
$4.47
|
| Rate for Payer: Blue Shield of California EPN |
$4.47
|
| Rate for Payer: Cash Price |
$184.93
|
| Rate for Payer: Cash Price |
$184.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$154.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.63
|
| Rate for Payer: Dignity Health Senior |
$4.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.19
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$155.67
|
| Rate for Payer: Heritage Provider Network Senior |
$155.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$160.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.30
|
| Rate for Payer: Multiplan Commercial |
$252.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$134.49
|
| Rate for Payer: TriValley Medical Group Senior |
$134.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$121.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$111.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4.63
|
|
|
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [38271]
|
Facility
|
IP
|
$336.23
|
|
|
Service Code
|
HCPCS J9074
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.86 |
| Max. Negotiated Rate |
$252.17 |
| Rate for Payer: Adventist Health Commercial |
$67.25
|
| Rate for Payer: Cash Price |
$184.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$154.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$181.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$155.67
|
| Rate for Payer: Heritage Provider Network Senior |
$155.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.06
|
| Rate for Payer: Multiplan Commercial |
$252.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$121.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$111.33
|
|
|
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [38271]
|
Facility
|
OP
|
$141.60
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$106.20 |
| Rate for Payer: Adventist Health Commercial |
$28.32
|
| Rate for Payer: Adventist Health Commercial |
$43.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$75.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$115.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$97.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$148.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.79
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.89
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cash Price |
$77.88
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cash Price |
$77.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$99.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$90.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$138.24
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.62
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$100.01
|
| Rate for Payer: Heritage Provider Network Senior |
$65.56
|
| Rate for Payer: Heritage Provider Network Senior |
$100.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$103.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$67.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$106.20
|
| Rate for Payer: Multiplan Commercial |
$162.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$86.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$56.64
|
| Rate for Payer: TriValley Medical Group Senior |
$56.64
|
| Rate for Payer: TriValley Medical Group Senior |
$86.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$78.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$51.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$46.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
|
|
CYCLOPHOSPHAMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080261]
|
Facility
|
OP
|
$5.30
|
|
|
Service Code
|
NDC 9994-0802-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.98
|
| Rate for Payer: Blue Shield of California Commercial |
$3.23
|
| Rate for Payer: Blue Shield of California EPN |
$2.59
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.50
|
| Rate for Payer: Dignity Health Senior |
$4.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.28
|
| Rate for Payer: Heritage Provider Network Senior |
$3.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.71
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.71
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.12
|
| Rate for Payer: TriValley Medical Group Senior |
$2.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.50
|
| Rate for Payer: Vantage Medical Group Senior |
$4.50
|
|
