|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 8770140733
|
| Hospital Charge Code |
1711815
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 5026834611
|
| Hospital Charge Code |
1711815
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 5026834615
|
| Hospital Charge Code |
1711815
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 5026834611
|
| Hospital Charge Code |
1711815
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 5026834615
|
| Hospital Charge Code |
1711815
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
FOLIC ACID 400 MCG TABLET [3234]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 8770140733
|
| Hospital Charge Code |
1711815
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 63323-184-11
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.99
|
| Rate for Payer: Blue Shield of California EPN |
$1.88
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: Dignity Health Senior |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.98
|
| Rate for Payer: Heritage Provider Network Senior |
$1.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Senior |
$1.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
OP
|
$5.90
|
|
|
Service Code
|
NDC 63323-184-10
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$5.02 |
| Rate for Payer: Adventist Health Commercial |
$1.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.42
|
| Rate for Payer: Blue Shield of California Commercial |
$3.66
|
| Rate for Payer: Blue Shield of California EPN |
$3.46
|
| Rate for Payer: Cash Price |
$2.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.02
|
| Rate for Payer: Dignity Health Senior |
$5.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.65
|
| Rate for Payer: Heritage Provider Network Senior |
$3.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$4.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Senior |
$2.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.02
|
| Rate for Payer: Vantage Medical Group Senior |
$5.02
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 39822-1100-1
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Blue Shield of California Commercial |
$2.61
|
| Rate for Payer: Blue Shield of California EPN |
$2.47
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Senior |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Senior |
$2.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Senior |
$1.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 39822-1100-1
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 63323-184-11
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.20
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.17
|
| Rate for Payer: Heritage Provider Network Senior |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
IP
|
$5.90
|
|
|
Service Code
|
NDC 63323-184-10
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Adventist Health Commercial |
$1.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.05
|
| Rate for Payer: Cash Price |
$2.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.99
|
| Rate for Payer: Heritage Provider Network Senior |
$3.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$4.42
|
|
|
FOLIC ACID ORAL SOLUTION COMPOUND 1 MG/ML [4080276]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 9994-0802-76
|
| Hospital Charge Code |
1715010
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
FOLIC ACID ORAL SOLUTION COMPOUND 1 MG/ML [4080276]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 9994-0802-76
|
| Hospital Charge Code |
1715010
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [22185]
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
CPT J1451
|
| Hospital Charge Code |
NDG22185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$217.20 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Adventist Health Commercial |
$240.00
|
| Rate for Payer: Adventist Health Commercial |
$157.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$541.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$824.40
|
| Rate for Payer: Cash Price |
$354.96
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$552.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$362.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$648.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$425.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$534.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$812.40
|
| Rate for Payer: Heritage Provider Network Senior |
$812.40
|
| Rate for Payer: Heritage Provider Network Senior |
$534.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$142.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$197.20
|
| Rate for Payer: Multiplan Commercial |
$900.00
|
| Rate for Payer: Multiplan Commercial |
$591.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$287.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$437.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$400.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$263.54
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [22185]
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
CPT J1451
|
| Hospital Charge Code |
NDG22185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Adventist Health Commercial |
$240.00
|
| Rate for Payer: Adventist Health Commercial |
$157.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$36.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$36.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$541.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$824.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Blue Shield of California Commercial |
$14.48
|
| Rate for Payer: Blue Shield of California Commercial |
$14.48
|
| Rate for Payer: Blue Shield of California EPN |
$14.48
|
| Rate for Payer: Blue Shield of California EPN |
$14.48
|
| Rate for Payer: Cash Price |
$354.96
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cash Price |
$354.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$552.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$362.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.66
|
| Rate for Payer: Dignity Health Senior |
$6.66
|
| Rate for Payer: Dignity Health Senior |
$6.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$768.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$504.83
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.06
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$555.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$365.21
|
| Rate for Payer: Heritage Provider Network Senior |
$365.21
|
| Rate for Payer: Heritage Provider Network Senior |
$555.60
|
| Rate for Payer: Humana Medicare |
$6.06
|
| Rate for Payer: Humana Medicare |
$6.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$142.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$197.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.63
|
| Rate for Payer: Multiplan Commercial |
$900.00
|
| Rate for Payer: Multiplan Commercial |
$591.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$315.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$480.00
|
| Rate for Payer: TriValley Medical Group Senior |
$315.52
|
| Rate for Payer: TriValley Medical Group Senior |
$480.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$287.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$437.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$263.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$400.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.66
|
| Rate for Payer: Vantage Medical Group Senior |
$6.06
|
| Rate for Payer: Vantage Medical Group Senior |
$6.06
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]
|
Facility
|
IP
|
$59.66
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
1722035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.80 |
| Max. Negotiated Rate |
$44.74 |
| Rate for Payer: Adventist Health Commercial |
$11.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.99
|
| Rate for Payer: Cash Price |
$26.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.39
|
| Rate for Payer: Heritage Provider Network Senior |
$40.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.92
|
| Rate for Payer: Multiplan Commercial |
$44.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.93
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]
|
Facility
|
OP
|
$59.66
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
1722035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Adventist Health Commercial |
$11.93
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$50.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$44.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.51
|
| Rate for Payer: Blue Shield of California Commercial |
$4.90
|
| Rate for Payer: Blue Shield of California EPN |
$4.90
|
| Rate for Payer: Cash Price |
$26.85
|
| Rate for Payer: Cash Price |
$26.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.71
|
| Rate for Payer: Dignity Health Senior |
$50.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.62
|
| Rate for Payer: Heritage Provider Network Senior |
$27.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.92
|
| Rate for Payer: Multiplan Commercial |
$44.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$23.86
|
| Rate for Payer: TriValley Medical Group Senior |
$23.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.71
|
| Rate for Payer: Vantage Medical Group Senior |
$50.71
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]
|
Facility
|
IP
|
$190.12
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
1721167
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.41 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: Adventist Health Commercial |
$38.02
|
| Rate for Payer: Adventist Health Commercial |
$21.73
|
| Rate for Payer: Adventist Health Commercial |
$22.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$130.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$75.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.64
|
| Rate for Payer: Cash Price |
$85.55
|
| Rate for Payer: Cash Price |
$49.77
|
| Rate for Payer: Cash Price |
$48.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$87.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$49.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$50.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$59.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$102.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$128.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.88
|
| Rate for Payer: Heritage Provider Network Senior |
$74.88
|
| Rate for Payer: Heritage Provider Network Senior |
$73.55
|
| Rate for Payer: Heritage Provider Network Senior |
$128.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.53
|
| Rate for Payer: Multiplan Commercial |
$142.59
|
| Rate for Payer: Multiplan Commercial |
$81.48
|
| Rate for Payer: Multiplan Commercial |
$82.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$69.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$63.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.95
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]
|
Facility
|
OP
|
$190.12
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
1721167
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$161.60 |
| Rate for Payer: Adventist Health Commercial |
$38.02
|
| Rate for Payer: Adventist Health Commercial |
$21.73
|
| Rate for Payer: Adventist Health Commercial |
$22.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$75.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$130.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$92.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$161.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$94.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$59.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$60.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$104.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$81.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$82.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$142.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.51
|
| Rate for Payer: Blue Shield of California Commercial |
$4.90
|
| Rate for Payer: Blue Shield of California Commercial |
$4.90
|
| Rate for Payer: Blue Shield of California Commercial |
$4.90
|
| Rate for Payer: Blue Shield of California EPN |
$4.90
|
| Rate for Payer: Blue Shield of California EPN |
$4.90
|
| Rate for Payer: Blue Shield of California EPN |
$4.90
|
| Rate for Payer: Cash Price |
$48.89
|
| Rate for Payer: Cash Price |
$85.55
|
| Rate for Payer: Cash Price |
$85.55
|
| Rate for Payer: Cash Price |
$48.89
|
| Rate for Payer: Cash Price |
$49.77
|
| Rate for Payer: Cash Price |
$49.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$87.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$50.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$49.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$94.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$92.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$161.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$161.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$92.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$94.01
|
| Rate for Payer: Dignity Health Senior |
$92.34
|
| Rate for Payer: Dignity Health Senior |
$94.01
|
| Rate for Payer: Dignity Health Senior |
$161.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$121.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.03
|
| Rate for Payer: Heritage Provider Network Senior |
$88.03
|
| Rate for Payer: Heritage Provider Network Senior |
$50.30
|
| Rate for Payer: Heritage Provider Network Senior |
$51.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$53.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$52.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$91.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.53
|
| Rate for Payer: Multiplan Commercial |
$81.48
|
| Rate for Payer: Multiplan Commercial |
$142.59
|
| Rate for Payer: Multiplan Commercial |
$82.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$76.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$44.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.46
|
| Rate for Payer: TriValley Medical Group Senior |
$43.46
|
| Rate for Payer: TriValley Medical Group Senior |
$76.05
|
| Rate for Payer: TriValley Medical Group Senior |
$44.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$69.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$63.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$94.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$161.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$92.34
|
| Rate for Payer: Vantage Medical Group Senior |
$92.34
|
| Rate for Payer: Vantage Medical Group Senior |
$94.01
|
| Rate for Payer: Vantage Medical Group Senior |
$161.60
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
|
IP
|
$25,117.15
|
|
|
Service Code
|
APR-DRG 3144
|
| Min. Negotiated Rate |
$25,117.15 |
| Max. Negotiated Rate |
$25,117.15 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25,117.15
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
|
IP
|
$9,803.70
|
|
|
Service Code
|
APR-DRG 3141
|
| Min. Negotiated Rate |
$9,803.70 |
| Max. Negotiated Rate |
$9,803.70 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,803.70
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
|
IP
|
$10,436.46
|
|
|
Service Code
|
APR-DRG 3142
|
| Min. Negotiated Rate |
$10,436.46 |
| Max. Negotiated Rate |
$10,436.46 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,436.46
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
|
IP
|
$13,842.99
|
|
|
Service Code
|
APR-DRG 3143
|
| Min. Negotiated Rate |
$13,842.99 |
| Max. Negotiated Rate |
$13,842.99 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,842.99
|
|
|
Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15731
|
| Min. Negotiated Rate |
$1,398.76 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,930.75
|
| Rate for Payer: Dignity Health Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,482.50
|
| Rate for Payer: Humana Medicare |
$4,482.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,398.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,482.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,516.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,289.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,647.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,647.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,930.75
|
| Rate for Payer: TriValley Medical Group Senior |
$4,482.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,482.50
|
|
