|
CYCLOPENTOLATE 1 % EYE DROPS >2 ML [4082025]
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 6131439603
|
| 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: Aetna of CA Non-Gatekeeper |
$1.44
|
| Rate for Payer: Cash Price |
$1.01
|
| 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 Foundation Hospitals 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
|
IP
|
$22.21
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$16.66 |
| Rate for Payer: Adventist Health Commercial |
$4.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.30
|
| Rate for Payer: Cash Price |
$9.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.28
|
| Rate for Payer: Heritage Provider Network Senior |
$10.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.55
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.35
|
|
|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS [9701]
|
Facility
|
OP
|
$22.21
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$18.88 |
| Rate for Payer: Adventist Health Commercial |
$4.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.73
|
| 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 |
$9.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.28
|
| Rate for Payer: Heritage Provider Network Senior |
$10.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$10.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 |
$8.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.35
|
| 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
|
|
|
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 |
$3.44 |
| Max. Negotiated Rate |
$504.32 |
| Rate for Payer: Adventist Health Commercial |
$134.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$415.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.68
|
| 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 |
$302.59
|
| Rate for Payer: Cash Price |
$302.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$309.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$430.36
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.44
|
| 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) Medicare Advantage |
$3.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$320.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$121.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.61
|
| 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 |
$4.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.78
|
| Rate for Payer: Vantage Medical Group Senior |
$3.78
|
|
|
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: Aetna of CA Non-Gatekeeper |
$433.04
|
| Rate for Payer: Cash Price |
$302.59
|
| 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 Foundation Hospitals 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
|
OP
|
$432.00
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.58 |
| 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 |
$42.00
|
| Rate for Payer: Adventist Health Commercial |
$56.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$266.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$187.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$175.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$129.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| 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 |
$194.40
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cash Price |
$127.44
|
| Rate for Payer: Cash Price |
$127.44
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cash Price |
$136.62
|
| Rate for Payer: Cash Price |
$136.62
|
| Rate for Payer: Cash Price |
$194.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$198.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$139.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$130.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$134.40
|
| 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 Medicare |
$0.58
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.58
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.58
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$200.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$131.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$97.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$140.57
|
| Rate for Payer: Heritage Provider Network Senior |
$200.02
|
| Rate for Payer: Heritage Provider Network Senior |
$140.57
|
| Rate for Payer: Heritage Provider Network Senior |
$97.23
|
| Rate for Payer: Heritage Provider Network Senior |
$131.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$135.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$206.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$144.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$100.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$38.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$54.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$78.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$51.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.78
|
| 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 |
$172.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$84.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$121.44
|
| 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 |
$109.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$75.87
|
| 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+ |
$69.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$143.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
|
|
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 |
$56.64
|
| Rate for Payer: Adventist Health Commercial |
$86.40
|
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$182.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$135.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$195.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$278.21
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cash Price |
$127.44
|
| Rate for Payer: Cash Price |
$136.62
|
| Rate for Payer: Cash Price |
$194.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.60
|
| 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 |
$139.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$233.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$163.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$97.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$131.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$200.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$140.57
|
| Rate for Payer: Heritage Provider Network Senior |
$140.57
|
| 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 |
$200.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$51.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$38.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$78.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$54.95
|
| 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: LLUH Dept of Risk Management WC |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$157.50
|
| Rate for Payer: Multiplan Commercial |
$227.70
|
| Rate for Payer: Multiplan Commercial |
$212.40
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$102.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$109.69
|
| 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+ |
$69.53
|
| 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
|
|
|
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 |
$0.58 |
| Max. Negotiated Rate |
$131.85 |
| Rate for Payer: Adventist Health Commercial |
$35.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$108.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| 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 |
$79.11
|
| Rate for Payer: Cash Price |
$79.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$80.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.51
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.58
|
| 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) Medicare Advantage |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$83.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$31.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.78
|
| 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 |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
|
|
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: Aetna of CA Non-Gatekeeper |
$113.22
|
| Rate for Payer: Cash Price |
$79.11
|
| 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 Foundation Hospitals 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 25 MG CAPSULE [206105]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
HCPCS J8530
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$3.93 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.10
|
| 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 |
$2.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.93
|
| 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 |
$1.62
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$2.70
|
| 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 |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| 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 |
$2.78
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| 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: Molina Healthcare of CA Medi-Cal/Medicare |
$4.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.52
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.40
|
| 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 |
$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
|
| 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 |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
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: Aetna of CA Non-Gatekeeper |
$2.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.86
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$2.70
|
| 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 |
$3.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.78
|
| Rate for Payer: Heritage Provider Network Senior |
$2.78
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| 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: Multiplan Commercial |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| 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+ |
$1.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.19
|
|
|
CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION [28922]
|
Facility
|
OP
|
$1,344.88
|
|
|
Service Code
|
HCPCS J9074
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$1,008.66 |
| Rate for Payer: Adventist Health Commercial |
$268.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$831.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.68
|
| 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 |
$605.20
|
| Rate for Payer: Cash Price |
$605.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$618.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$860.72
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$622.68
|
| Rate for Payer: Heritage Provider Network Senior |
$622.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$641.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$243.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$336.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.61
|
| Rate for Payer: Multiplan Commercial |
$1,008.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$537.95
|
| Rate for Payer: TriValley Medical Group Senior |
$537.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$485.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$445.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.78
|
| Rate for Payer: Vantage Medical Group Senior |
$3.78
|
|
|
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: Adventist Health Commercial |
$351.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$285.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,132.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$349.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$556.42
|
| Rate for Payer: Cash Price |
$791.10
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cash Price |
$244.08
|
| Rate for Payer: Cash Price |
$388.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$808.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$397.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$204.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$249.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$239.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$466.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$292.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$949.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$813.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$205.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$400.03
|
| 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 |
$813.95
|
| Rate for Payer: Heritage Provider Network Senior |
$205.57
|
| Rate for Payer: Heritage Provider Network Senior |
$400.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$80.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$318.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$156.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$98.17
|
| 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: LLUH Dept of Risk Management WC |
$111.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$439.50
|
| Rate for Payer: Multiplan Commercial |
$1,318.50
|
| Rate for Payer: Multiplan Commercial |
$406.80
|
| Rate for Payer: Multiplan Commercial |
$333.00
|
| Rate for Payer: Multiplan Commercial |
$648.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$160.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$195.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$635.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$312.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$582.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$179.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$147.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$286.07
|
|
|
CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION [28922]
|
Facility
|
IP
|
$1,344.88
|
|
|
Service Code
|
HCPCS J9074
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$243.42 |
| Max. Negotiated Rate |
$1,008.66 |
| Rate for Payer: Adventist Health Commercial |
$268.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$866.10
|
| Rate for Payer: Cash Price |
$605.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$618.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$726.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$622.68
|
| Rate for Payer: Heritage Provider Network Senior |
$622.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$243.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$336.22
|
| Rate for Payer: Multiplan Commercial |
$1,008.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$485.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$445.29
|
|
|
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 |
$0.58 |
| Max. Negotiated Rate |
$648.00 |
| Rate for Payer: Adventist Health Commercial |
$172.80
|
| Rate for Payer: Adventist Health Commercial |
$108.48
|
| Rate for Payer: Adventist Health Commercial |
$351.60
|
| Rate for Payer: Adventist Health Commercial |
$88.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$533.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$335.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$274.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,086.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| 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 |
$388.80
|
| Rate for Payer: Cash Price |
$791.10
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cash Price |
$791.10
|
| Rate for Payer: Cash Price |
$244.08
|
| Rate for Payer: Cash Price |
$244.08
|
| Rate for Payer: Cash Price |
$388.80
|
| 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 |
$808.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$204.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,125.12
|
| 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 |
$0.58
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.58
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.58
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.58
|
| 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 |
$813.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$251.13
|
| Rate for Payer: Heritage Provider Network Senior |
$400.03
|
| Rate for Payer: Heritage Provider Network Senior |
$251.13
|
| Rate for Payer: Heritage Provider Network Senior |
$813.95
|
| Rate for Payer: Heritage Provider Network Senior |
$205.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$211.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$412.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$258.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$838.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$318.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$98.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$156.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$80.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.00
|
| 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 |
$439.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$333.00
|
| Rate for Payer: Multiplan Commercial |
$1,318.50
|
| Rate for Payer: Multiplan Commercial |
$648.00
|
| Rate for Payer: Multiplan Commercial |
$406.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$345.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$177.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$703.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$216.96
|
| Rate for Payer: TriValley Medical Group Senior |
$703.20
|
| Rate for Payer: TriValley Medical Group Senior |
$177.60
|
| Rate for Payer: TriValley Medical Group Senior |
$345.60
|
| Rate for Payer: TriValley Medical Group Senior |
$216.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$195.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$635.17
|
| 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+ |
$179.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$147.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$582.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$286.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
|
|
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [38271]
|
Facility
|
IP
|
$141.60
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.63 |
| 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 Non-Gatekeeper |
$139.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$91.19
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cash Price |
$63.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$99.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$116.64
|
| 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 Foundation Hospitals Medi-Cal |
$39.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25.63
|
| 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: Multiplan Commercial |
$162.00
|
| Rate for Payer: Multiplan Commercial |
$106.20
|
| 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 |
$3.44 |
| Max. Negotiated Rate |
$252.17 |
| Rate for Payer: Cigna of CA HMO/PPO |
$154.67
|
| Rate for Payer: Adventist Health Commercial |
$67.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$207.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.68
|
| 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 |
$151.30
|
| Rate for Payer: Cash Price |
$151.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.19
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.44
|
| 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) Medicare Advantage |
$3.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$160.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$60.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.61
|
| 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 |
$4.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.78
|
| Rate for Payer: Vantage Medical Group Senior |
$3.78
|
|
|
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [38271]
|
Facility
|
OP
|
$216.00
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Adventist Health Commercial |
$43.20
|
| Rate for Payer: Adventist Health Commercial |
$28.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$87.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$133.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| 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 |
$97.20
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cash Price |
$63.72
|
| Rate for Payer: Cash Price |
$63.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$99.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$138.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$90.62
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.58
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$100.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.56
|
| Rate for Payer: Heritage Provider Network Senior |
$100.01
|
| Rate for Payer: Heritage Provider Network Senior |
$65.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$103.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$67.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$39.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.67
|
| 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: Molina Healthcare of CA Medi-Cal/Medicare |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$162.00
|
| Rate for Payer: Multiplan Commercial |
$106.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$56.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$86.40
|
| 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+ |
$71.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$46.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
|
|
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: Aetna of CA Non-Gatekeeper |
$216.53
|
| Rate for Payer: Cash Price |
$151.30
|
| 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 Foundation Hospitals 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 ORAL SUSPENSION COMPOUND 10 MG/ML [4080261]
|
Facility
|
IP
|
$5.30
|
|
|
Service Code
|
NDC 9994080261
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$3.98 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.41
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Senior |
$3.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
|
|
CYCLOPHOSPHAMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080261]
|
Facility
|
OP
|
$5.30
|
|
|
Service Code
|
NDC 9994080261
|
| 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 Non-Gatekeeper |
$3.28
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$2.65
|
| 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 |
$2.38
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$2.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS [216389]
|
Facility
|
IP
|
$140.86
|
|
|
Service Code
|
NDC 0023530105
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$105.64 |
| Rate for Payer: Adventist Health Commercial |
$28.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$90.71
|
| Rate for Payer: Cash Price |
$63.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$95.36
|
| Rate for Payer: Heritage Provider Network Senior |
$95.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.22
|
| Rate for Payer: Multiplan Commercial |
$105.64
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS [216389]
|
Facility
|
OP
|
$140.86
|
|
|
Service Code
|
NDC 0023530105
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$119.73 |
| Rate for Payer: Adventist Health Commercial |
$28.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$87.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$119.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$77.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$105.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$70.46
|
| Rate for Payer: Blue Shield of California Commercial |
$85.92
|
| Rate for Payer: Blue Shield of California EPN |
$68.74
|
| Rate for Payer: Cash Price |
$63.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$119.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$119.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$119.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$90.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$87.19
|
| Rate for Payer: Heritage Provider Network Senior |
$87.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$67.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$98.60
|
| Rate for Payer: Multiplan Commercial |
$105.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$56.34
|
| Rate for Payer: TriValley Medical Group Senior |
$56.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$70.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$70.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$119.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$119.73
|
| Rate for Payer: Vantage Medical Group Senior |
$119.73
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [35209]
|
Facility
|
OP
|
$5.60
|
|
|
Service Code
|
NDC 6050562021
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$4.76 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.80
|
| Rate for Payer: Blue Shield of California Commercial |
$3.42
|
| Rate for Payer: Blue Shield of California EPN |
$2.73
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Senior |
$3.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.92
|
| Rate for Payer: Multiplan Commercial |
$4.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.24
|
| Rate for Payer: TriValley Medical Group Senior |
$2.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.76
|
| Rate for Payer: Vantage Medical Group Senior |
$4.76
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [35209]
|
Facility
|
IP
|
$5.60
|
|
|
Service Code
|
NDC 6050562021
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.61
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.79
|
| Rate for Payer: Heritage Provider Network Senior |
$3.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.20
|
|
