|
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION [106804]
|
Facility
|
OP
|
$2,508.16
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.55 |
| Max. Negotiated Rate |
$1,881.12 |
| Rate for Payer: Adventist Health Commercial |
$501.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,550.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$37.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$33.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$45.09
|
| Rate for Payer: Blue Shield of California Commercial |
$29.55
|
| Rate for Payer: Blue Shield of California EPN |
$29.55
|
| Rate for Payer: Cash Price |
$1,128.67
|
| Rate for Payer: Cash Price |
$1,128.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,153.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$33.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,605.22
|
| Rate for Payer: EPIC Health Plan Medicare |
$30.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,161.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1,161.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$30.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,196.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$453.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$34.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$627.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$40.33
|
| Rate for Payer: Multiplan Commercial |
$1,881.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,003.26
|
| Rate for Payer: TriValley Medical Group Senior |
$1,003.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$906.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$830.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$37.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.11
|
| Rate for Payer: Vantage Medical Group Senior |
$33.11
|
|
|
DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE [105502]
|
Facility
|
IP
|
$2,318.03
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$419.56 |
| Max. Negotiated Rate |
$1,738.52 |
| Rate for Payer: Adventist Health Commercial |
$463.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,492.81
|
| Rate for Payer: Cash Price |
$1,043.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,066.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,251.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,073.25
|
| Rate for Payer: Heritage Provider Network Senior |
$1,073.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$419.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$579.51
|
| Rate for Payer: Multiplan Commercial |
$1,738.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$837.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$767.50
|
|
|
DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE [105502]
|
Facility
|
OP
|
$2,318.03
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.55 |
| Max. Negotiated Rate |
$1,738.52 |
| Rate for Payer: Adventist Health Commercial |
$463.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,432.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$37.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$33.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$45.09
|
| Rate for Payer: Blue Shield of California Commercial |
$29.55
|
| Rate for Payer: Blue Shield of California EPN |
$29.55
|
| Rate for Payer: Cash Price |
$1,043.11
|
| Rate for Payer: Cash Price |
$1,043.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,066.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$33.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,483.54
|
| Rate for Payer: EPIC Health Plan Medicare |
$30.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,073.25
|
| Rate for Payer: Heritage Provider Network Senior |
$1,073.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$30.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,105.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$419.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$34.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$579.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$40.33
|
| Rate for Payer: Multiplan Commercial |
$1,738.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$927.21
|
| Rate for Payer: TriValley Medical Group Senior |
$927.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$837.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$767.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$37.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.11
|
| Rate for Payer: Vantage Medical Group Senior |
$33.11
|
|
|
DENOSUMAB-BBDZ 60 MG/ML SUBCUTANEOUS SYRINGE [245944]
|
Facility
|
OP
|
$1,924.96
|
|
|
Service Code
|
HCPCS Q5136
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.67 |
| Max. Negotiated Rate |
$1,443.72 |
| Rate for Payer: Adventist Health Commercial |
$384.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,189.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$41.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$30.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.73
|
| Rate for Payer: Blue Shield of California Commercial |
$1,174.23
|
| Rate for Payer: Blue Shield of California EPN |
$939.38
|
| Rate for Payer: Cash Price |
$866.23
|
| Rate for Payer: Cash Price |
$866.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$885.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$41.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.44
|
| Rate for Payer: Dignity Health Medicare Advantage |
$27.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,231.97
|
| Rate for Payer: EPIC Health Plan Medicare |
$27.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$891.26
|
| Rate for Payer: Heritage Provider Network Senior |
$891.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$27.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$918.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$348.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$31.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$481.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$37.08
|
| Rate for Payer: Multiplan Commercial |
$1,443.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$769.98
|
| Rate for Payer: TriValley Medical Group Senior |
$769.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$695.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$637.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$41.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.44
|
| Rate for Payer: Vantage Medical Group Senior |
$27.67
|
|
|
DENOSUMAB-BBDZ 60 MG/ML SUBCUTANEOUS SYRINGE [245944]
|
Facility
|
IP
|
$1,924.96
|
|
|
Service Code
|
HCPCS Q5136
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$348.42 |
| Max. Negotiated Rate |
$1,443.72 |
| Rate for Payer: Adventist Health Commercial |
$384.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,239.67
|
| Rate for Payer: Cash Price |
$866.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$885.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,039.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$891.26
|
| Rate for Payer: Heritage Provider Network Senior |
$891.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$348.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$481.24
|
| Rate for Payer: Multiplan Commercial |
$1,443.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$695.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$637.35
|
|
|
DENOSUMAB-BMWO 60 MG/ML SUBCUTANEOUS SYRINGE [246286]
|
Facility
|
OP
|
$2,137.99
|
|
|
Service Code
|
HCPCS Q5157
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.98 |
| Max. Negotiated Rate |
$1,603.49 |
| Rate for Payer: Adventist Health Commercial |
$427.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,321.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$28.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$69.13
|
| Rate for Payer: Blue Shield of California Commercial |
$1,304.17
|
| Rate for Payer: Blue Shield of California EPN |
$1,043.34
|
| Rate for Payer: Cash Price |
$962.10
|
| Rate for Payer: Cash Price |
$962.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$983.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$25.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,368.31
|
| Rate for Payer: EPIC Health Plan Medicare |
$25.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$989.89
|
| Rate for Payer: Heritage Provider Network Senior |
$989.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$25.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,019.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$386.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$29.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$534.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$34.81
|
| Rate for Payer: Multiplan Commercial |
$1,603.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$855.20
|
| Rate for Payer: TriValley Medical Group Senior |
$855.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$772.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$707.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.58
|
| Rate for Payer: Vantage Medical Group Senior |
$25.98
|
|
|
DENOSUMAB-BMWO 60 MG/ML SUBCUTANEOUS SYRINGE [246286]
|
Facility
|
IP
|
$2,137.99
|
|
|
Service Code
|
HCPCS Q5157
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$386.98 |
| Max. Negotiated Rate |
$1,603.49 |
| Rate for Payer: Adventist Health Commercial |
$427.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,376.87
|
| Rate for Payer: Cash Price |
$962.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$983.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,154.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$989.89
|
| Rate for Payer: Heritage Provider Network Senior |
$989.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$386.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$534.50
|
| Rate for Payer: Multiplan Commercial |
$1,603.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$772.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$707.89
|
|
|
DENOSUMAB-DSSB 60 MG/ML SUBCUTANEOUS SYRINGE [247538]
|
Facility
|
IP
|
$1,170.00
|
|
|
Service Code
|
HCPCS Q5159
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$211.77 |
| Max. Negotiated Rate |
$877.50 |
| Rate for Payer: Adventist Health Commercial |
$234.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$753.48
|
| Rate for Payer: Cash Price |
$526.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$538.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$631.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$541.71
|
| Rate for Payer: Heritage Provider Network Senior |
$541.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$211.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$292.50
|
| Rate for Payer: Multiplan Commercial |
$877.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$422.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$387.39
|
|
|
DENOSUMAB-DSSB 60 MG/ML SUBCUTANEOUS SYRINGE [247538]
|
Facility
|
OP
|
$1,170.00
|
|
|
Service Code
|
HCPCS Q5159
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.44 |
| Max. Negotiated Rate |
$994.50 |
| Rate for Payer: Adventist Health Commercial |
$234.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$723.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$994.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$643.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$877.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.44
|
| Rate for Payer: Blue Shield of California Commercial |
$713.70
|
| Rate for Payer: Blue Shield of California EPN |
$570.96
|
| Rate for Payer: Cash Price |
$526.50
|
| Rate for Payer: Cash Price |
$526.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$538.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$994.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$994.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$994.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$748.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$541.71
|
| Rate for Payer: Heritage Provider Network Senior |
$541.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$558.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$211.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$292.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$819.00
|
| Rate for Payer: Multiplan Commercial |
$877.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$468.00
|
| Rate for Payer: TriValley Medical Group Senior |
$468.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$422.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$387.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$994.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$994.50
|
| Rate for Payer: Vantage Medical Group Senior |
$994.50
|
|
|
DENOSUMAB-NXXP 60 MG/ML SUBCUTANEOUS SYRINGE [247605]
|
Facility
|
IP
|
$1,012.80
|
|
|
Service Code
|
HCPCS Q5162
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$183.32 |
| Max. Negotiated Rate |
$759.60 |
| Rate for Payer: Adventist Health Commercial |
$202.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$652.24
|
| Rate for Payer: Cash Price |
$455.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$465.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$546.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$468.93
|
| Rate for Payer: Heritage Provider Network Senior |
$468.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$183.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$253.20
|
| Rate for Payer: Multiplan Commercial |
$759.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$365.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$335.34
|
|
|
DENOSUMAB-NXXP 60 MG/ML SUBCUTANEOUS SYRINGE [247605]
|
Facility
|
OP
|
$1,012.80
|
|
|
Service Code
|
HCPCS Q5162
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.66 |
| Max. Negotiated Rate |
$759.60 |
| Rate for Payer: Adventist Health Commercial |
$202.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$625.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$506.60
|
| Rate for Payer: Blue Shield of California Commercial |
$617.81
|
| Rate for Payer: Blue Shield of California EPN |
$494.25
|
| Rate for Payer: Cash Price |
$455.76
|
| Rate for Payer: Cash Price |
$455.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$465.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$648.19
|
| Rate for Payer: EPIC Health Plan Medicare |
$15.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$468.93
|
| Rate for Payer: Heritage Provider Network Senior |
$468.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$483.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$183.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$253.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20.98
|
| Rate for Payer: Multiplan Commercial |
$759.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$405.12
|
| Rate for Payer: TriValley Medical Group Senior |
$405.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$365.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$335.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.23
|
| Rate for Payer: Vantage Medical Group Senior |
$15.66
|
|
|
DENOSUMAB-QBDE 60 MG/ML SUBCUTANEOUS SYRINGE [248500]
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
HCPCS Q5167
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.88 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Adventist Health Commercial |
$96.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$309.12
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$220.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$259.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$222.24
|
| Rate for Payer: Heritage Provider Network Senior |
$222.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$86.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.00
|
| Rate for Payer: Multiplan Commercial |
$360.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$173.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$158.93
|
|
|
DENOSUMAB-QBDE 60 MG/ML SUBCUTANEOUS SYRINGE [248500]
|
Facility
|
OP
|
$480.00
|
|
|
Service Code
|
HCPCS Q5167
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.12 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Adventist Health Commercial |
$96.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$296.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$240.10
|
| Rate for Payer: Blue Shield of California Commercial |
$292.80
|
| Rate for Payer: Blue Shield of California EPN |
$234.24
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$220.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$307.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$222.24
|
| Rate for Payer: Heritage Provider Network Senior |
$222.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$228.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$86.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$360.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$192.00
|
| Rate for Payer: TriValley Medical Group Senior |
$192.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$173.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$158.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.53
|
| Rate for Payer: Vantage Medical Group Senior |
$4.12
|
|
|
DENTAL AND ORAL DISEASES WITH CC
|
Facility
|
IP
|
$14,672.01
|
|
|
Service Code
|
MSDRG 158
|
| Min. Negotiated Rate |
$10,949.26 |
| Max. Negotiated Rate |
$14,672.01 |
| Rate for Payer: EPIC Health Plan Medicare |
$10,949.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10,949.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$12,591.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$14,672.01
|
|
|
DENTAL AND ORAL DISEASES WITH MCC
|
Facility
|
IP
|
$27,063.87
|
|
|
Service Code
|
MSDRG 157
|
| Min. Negotiated Rate |
$20,196.92 |
| Max. Negotiated Rate |
$27,063.87 |
| Rate for Payer: EPIC Health Plan Medicare |
$20,196.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20,196.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23,226.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$27,063.87
|
|
|
DENTAL AND ORAL DISEASES WITHOUT CC/MCC
|
Facility
|
IP
|
$11,580.96
|
|
|
Service Code
|
MSDRG 159
|
| Min. Negotiated Rate |
$8,642.51 |
| Max. Negotiated Rate |
$11,580.96 |
| Rate for Payer: EPIC Health Plan Medicare |
$8,642.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,642.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9,938.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11,580.96
|
|
|
DEPRESSIVE NEUROSES
|
Facility
|
IP
|
$15,149.57
|
|
|
Service Code
|
MSDRG 881
|
| Min. Negotiated Rate |
$11,305.65 |
| Max. Negotiated Rate |
$15,149.57 |
| Rate for Payer: EPIC Health Plan Medicare |
$11,305.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11,305.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,001.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15,149.57
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 4596334202
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Senior |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 5074211301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 4596334202
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 5074211301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
DESMOPRESSIN 0.1 MG TABLET [16052]
|
Facility
|
IP
|
$2.63
|
|
|
Service Code
|
NDC 6068772111
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.69
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.78
|
| Rate for Payer: Heritage Provider Network Senior |
$1.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$1.97
|
|
|
DESMOPRESSIN 0.1 MG TABLET [16052]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 6800157400
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
|
|
DESMOPRESSIN 0.1 MG TABLET [16052]
|
Facility
|
OP
|
$2.63
|
|
|
Service Code
|
NDC 6068772111
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.32
|
| Rate for Payer: Blue Shield of California Commercial |
$1.60
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.63
|
| Rate for Payer: Heritage Provider Network Senior |
$1.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$1.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Senior |
$1.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Vantage Medical Group Senior |
$2.24
|
|
|
DESMOPRESSIN 0.1 MG TABLET [16052]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 6800157400
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.75
|
|
