|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS J0894
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.43 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: TriValley Medical Group Senior |
$48.00
|
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Adventist Health Commercial |
$47.52
|
| Rate for Payer: Adventist Health Commercial |
$115.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$355.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$146.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$489.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$201.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$316.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$130.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$90.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$432.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$178.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.65
|
| Rate for Payer: Blue Shield of California Commercial |
$6.43
|
| Rate for Payer: Blue Shield of California Commercial |
$6.43
|
| Rate for Payer: Blue Shield of California Commercial |
$6.43
|
| Rate for Payer: Blue Shield of California EPN |
$6.43
|
| Rate for Payer: Blue Shield of California EPN |
$6.43
|
| Rate for Payer: Blue Shield of California EPN |
$6.43
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$264.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$489.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$201.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$201.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$489.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$201.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$489.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$102.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$368.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$266.69
|
| Rate for Payer: Heritage Provider Network Senior |
$110.01
|
| Rate for Payer: Heritage Provider Network Senior |
$55.56
|
| Rate for Payer: Heritage Provider Network Senior |
$266.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$274.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$113.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$57.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$104.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$43.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$144.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$84.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$403.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$166.32
|
| Rate for Payer: Multiplan Commercial |
$178.20
|
| Rate for Payer: Multiplan Commercial |
$432.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$95.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$48.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$230.40
|
| Rate for Payer: TriValley Medical Group Senior |
$230.40
|
| Rate for Payer: TriValley Medical Group Senior |
$95.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$208.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$85.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$78.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$190.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$489.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$201.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$489.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$201.96
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
| Rate for Payer: Vantage Medical Group Senior |
$489.60
|
| Rate for Payer: Vantage Medical Group Senior |
$201.96
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
|
IP
|
$576.00
|
|
|
Service Code
|
HCPCS J0894
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.26 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Adventist Health Commercial |
$115.20
|
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Adventist Health Commercial |
$47.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$370.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$153.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.28
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$264.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$128.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$311.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$266.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.01
|
| Rate for Payer: Heritage Provider Network Senior |
$110.01
|
| Rate for Payer: Heritage Provider Network Senior |
$55.56
|
| Rate for Payer: Heritage Provider Network Senior |
$266.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$43.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$104.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$432.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$178.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$208.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$85.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$190.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$78.67
|
|
|
DEFERASIROX 180 MG TABLET [206427]
|
Facility
|
IP
|
$145.49
|
|
|
Service Code
|
NDC 0078065515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.33 |
| Max. Negotiated Rate |
$109.12 |
| Rate for Payer: Adventist Health Commercial |
$29.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$93.70
|
| Rate for Payer: Cash Price |
$65.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$78.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$98.50
|
| Rate for Payer: Heritage Provider Network Senior |
$98.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.37
|
| Rate for Payer: Multiplan Commercial |
$109.12
|
|
|
DEFERASIROX 180 MG TABLET [206427]
|
Facility
|
OP
|
$145.49
|
|
|
Service Code
|
NDC 0078065515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.33 |
| Max. Negotiated Rate |
$123.67 |
| Rate for Payer: Adventist Health Commercial |
$29.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$89.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$123.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$80.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$109.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.77
|
| Rate for Payer: Blue Shield of California Commercial |
$88.75
|
| Rate for Payer: Blue Shield of California EPN |
$71.00
|
| Rate for Payer: Cash Price |
$65.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$94.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$123.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$123.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$90.06
|
| Rate for Payer: Heritage Provider Network Senior |
$90.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$69.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$101.84
|
| Rate for Payer: Multiplan Commercial |
$109.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$58.20
|
| Rate for Payer: TriValley Medical Group Senior |
$58.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$72.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$72.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$123.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$123.67
|
| Rate for Payer: Vantage Medical Group Senior |
$123.67
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
|
OP
|
$127.17
|
|
|
Service Code
|
NDC 0078046915
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.02 |
| Max. Negotiated Rate |
$108.09 |
| Rate for Payer: Adventist Health Commercial |
$25.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$78.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$108.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$95.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$63.61
|
| Rate for Payer: Blue Shield of California Commercial |
$77.57
|
| Rate for Payer: Blue Shield of California EPN |
$62.06
|
| Rate for Payer: Cash Price |
$57.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$82.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$108.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$108.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$108.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$78.72
|
| Rate for Payer: Heritage Provider Network Senior |
$78.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$60.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$89.02
|
| Rate for Payer: Multiplan Commercial |
$95.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$50.87
|
| Rate for Payer: TriValley Medical Group Senior |
$50.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$63.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$63.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$108.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$108.09
|
| Rate for Payer: Vantage Medical Group Senior |
$108.09
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
|
IP
|
$127.17
|
|
|
Service Code
|
NDC 0078046915
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.02 |
| Max. Negotiated Rate |
$95.38 |
| Rate for Payer: Adventist Health Commercial |
$25.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$81.90
|
| Rate for Payer: Cash Price |
$57.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$86.09
|
| Rate for Payer: Heritage Provider Network Senior |
$86.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.79
|
| Rate for Payer: Multiplan Commercial |
$95.38
|
|
|
DEFERASIROX 360 MG TABLET [206428]
|
Facility
|
IP
|
$290.97
|
|
|
Service Code
|
NDC 0078065615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$52.67 |
| Max. Negotiated Rate |
$218.23 |
| Rate for Payer: Adventist Health Commercial |
$58.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$187.38
|
| Rate for Payer: Cash Price |
$130.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$157.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$196.99
|
| Rate for Payer: Heritage Provider Network Senior |
$196.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$52.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.74
|
| Rate for Payer: Multiplan Commercial |
$218.23
|
|
|
DEFERASIROX 360 MG TABLET [206428]
|
Facility
|
OP
|
$290.97
|
|
|
Service Code
|
NDC 0078065615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$52.67 |
| Max. Negotiated Rate |
$247.32 |
| Rate for Payer: Adventist Health Commercial |
$58.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$179.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$247.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$160.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$218.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$145.54
|
| Rate for Payer: Blue Shield of California Commercial |
$177.49
|
| Rate for Payer: Blue Shield of California EPN |
$141.99
|
| Rate for Payer: Cash Price |
$130.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$189.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$247.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$247.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$247.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$186.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$180.11
|
| Rate for Payer: Heritage Provider Network Senior |
$180.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$138.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$52.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$203.68
|
| Rate for Payer: Multiplan Commercial |
$218.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$116.39
|
| Rate for Payer: TriValley Medical Group Senior |
$116.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$145.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$145.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$247.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$247.32
|
| Rate for Payer: Vantage Medical Group Senior |
$247.32
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
|
OP
|
$254.34
|
|
|
Service Code
|
NDC 0078047015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.04 |
| Max. Negotiated Rate |
$216.19 |
| Rate for Payer: Adventist Health Commercial |
$50.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$157.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$216.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$139.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$190.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$127.22
|
| Rate for Payer: Blue Shield of California Commercial |
$155.15
|
| Rate for Payer: Blue Shield of California EPN |
$124.12
|
| Rate for Payer: Cash Price |
$114.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$165.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$216.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$216.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$216.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$157.44
|
| Rate for Payer: Heritage Provider Network Senior |
$157.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$121.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$46.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$178.04
|
| Rate for Payer: Multiplan Commercial |
$190.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$101.74
|
| Rate for Payer: TriValley Medical Group Senior |
$101.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$127.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$127.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$216.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$216.19
|
| Rate for Payer: Vantage Medical Group Senior |
$216.19
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
|
IP
|
$254.34
|
|
|
Service Code
|
NDC 0078047015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.04 |
| Max. Negotiated Rate |
$190.75 |
| Rate for Payer: Adventist Health Commercial |
$50.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$163.79
|
| Rate for Payer: Cash Price |
$114.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$172.19
|
| Rate for Payer: Heritage Provider Network Senior |
$172.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$46.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.59
|
| Rate for Payer: Multiplan Commercial |
$190.75
|
|
|
DEFERASIROX 90 MG TABLET [206426]
|
Facility
|
OP
|
$72.75
|
|
|
Service Code
|
NDC 0078065415
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.17 |
| Max. Negotiated Rate |
$61.84 |
| Rate for Payer: Adventist Health Commercial |
$14.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$44.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$40.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$36.39
|
| Rate for Payer: Blue Shield of California Commercial |
$44.38
|
| Rate for Payer: Blue Shield of California EPN |
$35.50
|
| Rate for Payer: Cash Price |
$32.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$47.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$61.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$45.03
|
| Rate for Payer: Heritage Provider Network Senior |
$45.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$34.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50.92
|
| Rate for Payer: Multiplan Commercial |
$54.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$29.10
|
| Rate for Payer: TriValley Medical Group Senior |
$29.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.84
|
| Rate for Payer: Vantage Medical Group Senior |
$61.84
|
|
|
DEFERASIROX 90 MG TABLET [206426]
|
Facility
|
IP
|
$72.75
|
|
|
Service Code
|
NDC 0078065415
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.17 |
| Max. Negotiated Rate |
$54.56 |
| Rate for Payer: Adventist Health Commercial |
$14.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$46.85
|
| Rate for Payer: Cash Price |
$32.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$49.25
|
| Rate for Payer: Heritage Provider Network Senior |
$49.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.19
|
| Rate for Payer: Multiplan Commercial |
$54.56
|
|
|
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]
|
Facility
|
IP
|
$49.44
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$37.08 |
| Rate for Payer: Adventist Health Commercial |
$9.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.84
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.89
|
| Rate for Payer: Heritage Provider Network Senior |
$22.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.36
|
| Rate for Payer: Multiplan Commercial |
$37.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.37
|
|
|
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]
|
Facility
|
OP
|
$49.44
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$42.02 |
| Rate for Payer: Adventist Health Commercial |
$9.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.84
|
| Rate for Payer: Blue Shield of California Commercial |
$11.53
|
| Rate for Payer: Blue Shield of California EPN |
$11.53
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$42.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.89
|
| Rate for Payer: Heritage Provider Network Senior |
$22.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$23.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$34.61
|
| Rate for Payer: Multiplan Commercial |
$37.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.78
|
| Rate for Payer: TriValley Medical Group Senior |
$19.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.02
|
| Rate for Payer: Vantage Medical Group Senior |
$42.02
|
|
|
DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]
|
Facility
|
OP
|
$17.71
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$32.84 |
| Rate for Payer: Adventist Health Commercial |
$3.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.84
|
| Rate for Payer: Blue Shield of California Commercial |
$11.53
|
| Rate for Payer: Blue Shield of California EPN |
$11.53
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.20
|
| Rate for Payer: Heritage Provider Network Senior |
$8.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.40
|
| Rate for Payer: Multiplan Commercial |
$13.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.08
|
| Rate for Payer: TriValley Medical Group Senior |
$7.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.05
|
| Rate for Payer: Vantage Medical Group Senior |
$15.05
|
|
|
DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]
|
Facility
|
IP
|
$17.71
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$13.28 |
| Rate for Payer: Adventist Health Commercial |
$3.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.41
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.20
|
| Rate for Payer: Heritage Provider Network Senior |
$8.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.43
|
| Rate for Payer: Multiplan Commercial |
$13.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.86
|
|
|
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION [9723]
|
Facility
|
OP
|
$15.54
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$32.84 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Adventist Health Commercial |
$3.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.84
|
| Rate for Payer: Blue Shield of California Commercial |
$11.53
|
| Rate for Payer: Blue Shield of California Commercial |
$11.53
|
| Rate for Payer: Blue Shield of California EPN |
$11.53
|
| Rate for Payer: Blue Shield of California EPN |
$11.53
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.20
|
| Rate for Payer: Heritage Provider Network Senior |
$8.20
|
| Rate for Payer: Heritage Provider Network Senior |
$7.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.88
|
| Rate for Payer: Multiplan Commercial |
$13.28
|
| Rate for Payer: Multiplan Commercial |
$11.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.08
|
| Rate for Payer: TriValley Medical Group Senior |
$6.22
|
| Rate for Payer: TriValley Medical Group Senior |
$7.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.05
|
| Rate for Payer: Vantage Medical Group Senior |
$15.05
|
| Rate for Payer: Vantage Medical Group Senior |
$13.21
|
|
|
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION [9723]
|
Facility
|
IP
|
$15.54
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$11.65 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Adventist Health Commercial |
$3.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.41
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.20
|
| Rate for Payer: Heritage Provider Network Senior |
$8.20
|
| Rate for Payer: Heritage Provider Network Senior |
$7.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.43
|
| Rate for Payer: Multiplan Commercial |
$11.65
|
| Rate for Payer: Multiplan Commercial |
$13.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.15
|
|
|
DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION [214034]
|
Facility
|
IP
|
$595.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.73 |
| Max. Negotiated Rate |
$446.40 |
| Rate for Payer: Adventist Health Commercial |
$119.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$383.31
|
| Rate for Payer: Cash Price |
$267.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$273.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$321.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$275.58
|
| Rate for Payer: Heritage Provider Network Senior |
$275.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$107.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.80
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$215.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$197.07
|
|
|
DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION [214034]
|
Facility
|
OP
|
$595.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.73 |
| Max. Negotiated Rate |
$505.92 |
| Rate for Payer: Adventist Health Commercial |
$119.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$367.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$505.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$327.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$446.40
|
| Rate for Payer: Blue Shield of California Commercial |
$363.07
|
| Rate for Payer: Blue Shield of California EPN |
$290.46
|
| Rate for Payer: Cash Price |
$267.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$273.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$505.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$505.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$505.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$380.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$275.58
|
| Rate for Payer: Heritage Provider Network Senior |
$275.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$283.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$107.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$416.64
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$238.08
|
| Rate for Payer: TriValley Medical Group Senior |
$238.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$215.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$197.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$505.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$505.92
|
| Rate for Payer: Vantage Medical Group Senior |
$505.92
|
|
|
DEGARELIX 80 MG SUBCUTANEOUS SOLUTION [96986]
|
Facility
|
IP
|
$586.14
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.09 |
| Max. Negotiated Rate |
$439.61 |
| Rate for Payer: Adventist Health Commercial |
$117.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$377.47
|
| Rate for Payer: Cash Price |
$263.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$269.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$316.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$271.38
|
| Rate for Payer: Heritage Provider Network Senior |
$271.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$106.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$146.53
|
| Rate for Payer: Multiplan Commercial |
$439.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$211.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$194.07
|
|
|
DEGARELIX 80 MG SUBCUTANEOUS SOLUTION [96986]
|
Facility
|
OP
|
$586.14
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$439.61 |
| Rate for Payer: Adventist Health Commercial |
$117.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$362.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$6.23
|
| Rate for Payer: Blue Shield of California EPN |
$6.23
|
| Rate for Payer: Cash Price |
$263.76
|
| Rate for Payer: Cash Price |
$263.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$269.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.93
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$375.13
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$271.38
|
| Rate for Payer: Heritage Provider Network Senior |
$271.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$279.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$106.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$146.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$439.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$234.46
|
| Rate for Payer: TriValley Medical Group Senior |
$234.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$211.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$194.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.93
|
| Rate for Payer: Vantage Medical Group Senior |
$4.93
|
|
|
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC
|
Facility
|
IP
|
$36,373.87
|
|
|
Service Code
|
MSDRG 056
|
| Min. Negotiated Rate |
$27,144.68 |
| Max. Negotiated Rate |
$36,373.87 |
| Rate for Payer: EPIC Health Plan Medicare |
$27,144.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$27,144.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$31,216.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$36,373.87
|
|
|
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC
|
Facility
|
IP
|
$20,596.15
|
|
|
Service Code
|
MSDRG 057
|
| Min. Negotiated Rate |
$15,370.26 |
| Max. Negotiated Rate |
$20,596.15 |
| Rate for Payer: EPIC Health Plan Medicare |
$15,370.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15,370.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17,675.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20,596.15
|
|
|
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION [106804]
|
Facility
|
IP
|
$2,508.16
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$453.98 |
| Max. Negotiated Rate |
$1,881.12 |
| Rate for Payer: Adventist Health Commercial |
$501.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,615.26
|
| Rate for Payer: Cash Price |
$1,128.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,153.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,354.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,161.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1,161.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$453.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$627.04
|
| Rate for Payer: Multiplan Commercial |
$1,881.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$906.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$830.45
|
|
