|
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SYRINGE [114048]
|
Facility
|
IP
|
$3.47
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Adventist Health Commercial |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.23
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$2.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.15
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SYRINGE [114048]
|
Facility
|
OP
|
$3.47
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$3.14 |
| Rate for Payer: Adventist Health Commercial |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$2.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.39
|
| Rate for Payer: TriValley Medical Group Senior |
$1.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.95
|
| Rate for Payer: Vantage Medical Group Senior |
$2.95
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [118427]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$6.75 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Adventist Health Commercial |
$1.04
|
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.36
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.41
|
| Rate for Payer: Heritage Provider Network Senior |
$4.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Multiplan Commercial |
$3.91
|
| Rate for Payer: Multiplan Commercial |
$3.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.75
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [118427]
|
Facility
|
OP
|
$5.21
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$4.43 |
| Rate for Payer: Adventist Health Commercial |
$1.04
|
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.17
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.41
|
| Rate for Payer: Heritage Provider Network Senior |
$4.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.70
|
| Rate for Payer: Multiplan Commercial |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Multiplan Commercial |
$3.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Senior |
$3.60
|
| Rate for Payer: TriValley Medical Group Senior |
$2.11
|
| Rate for Payer: TriValley Medical Group Senior |
$2.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.49
|
| Rate for Payer: Vantage Medical Group Senior |
$4.43
|
| Rate for Payer: Vantage Medical Group Senior |
$7.65
|
| Rate for Payer: Vantage Medical Group Senior |
$4.49
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE [225593]
|
Facility
|
IP
|
$6.94
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.21 |
| Rate for Payer: Adventist Health Commercial |
$1.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.47
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.21
|
| Rate for Payer: Heritage Provider Network Senior |
$3.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.74
|
| Rate for Payer: Multiplan Commercial |
$5.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.30
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE [225593]
|
Facility
|
OP
|
$6.94
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$5.90 |
| Rate for Payer: Adventist Health Commercial |
$1.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.21
|
| Rate for Payer: Heritage Provider Network Senior |
$3.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.86
|
| Rate for Payer: Multiplan Commercial |
$5.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.78
|
| Rate for Payer: TriValley Medical Group Senior |
$2.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.90
|
| Rate for Payer: Vantage Medical Group Senior |
$5.90
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
OP
|
$14.40
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$12.24 |
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.80
|
| Rate for Payer: Blue Shield of California Commercial |
$8.78
|
| Rate for Payer: Blue Shield of California Commercial |
$4.12
|
| Rate for Payer: Blue Shield of California EPN |
$3.29
|
| Rate for Payer: Blue Shield of California EPN |
$7.03
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.74
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.74
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.13
|
| Rate for Payer: Heritage Provider Network Senior |
$6.67
|
| Rate for Payer: Heritage Provider Network Senior |
$3.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.08
|
| Rate for Payer: Multiplan Commercial |
$5.06
|
| Rate for Payer: Multiplan Commercial |
$10.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Senior |
$5.76
|
| Rate for Payer: TriValley Medical Group Senior |
$2.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.74
|
| Rate for Payer: Vantage Medical Group Senior |
$5.74
|
| Rate for Payer: Vantage Medical Group Senior |
$12.24
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
IP
|
$6.75
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$5.06 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.35
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.13
|
| Rate for Payer: Heritage Provider Network Senior |
$3.13
|
| Rate for Payer: Heritage Provider Network Senior |
$6.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.69
|
| Rate for Payer: Multiplan Commercial |
$10.80
|
| Rate for Payer: Multiplan Commercial |
$5.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.77
|
|
|
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
|
|
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201904]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201904]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
|
|
DEXMEDETOMIDINE (PF) 100 MCG/ML INTRAVENOUS SOLUTION [249449]
|
Facility
|
OP
|
$2.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.24
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California Commercial |
$1.98
|
| Rate for Payer: Blue Shield of California Commercial |
$1.23
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$1.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$2.11
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Senior |
$1.50
|
| Rate for Payer: Heritage Provider Network Senior |
$2.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$3.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.81
|
| Rate for Payer: TriValley Medical Group Senior |
$0.81
|
| Rate for Payer: TriValley Medical Group Senior |
$1.73
|
| Rate for Payer: TriValley Medical Group Senior |
$1.30
|
| Rate for Payer: TriValley Medical Group Senior |
$1.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.67
|
| Rate for Payer: Vantage Medical Group Senior |
$2.68
|
| Rate for Payer: Vantage Medical Group Senior |
$1.72
|
| Rate for Payer: Vantage Medical Group Senior |
$3.67
|
| Rate for Payer: Vantage Medical Group Senior |
$2.76
|
|
|
DEXMEDETOMIDINE (PF) 100 MCG/ML INTRAVENOUS SOLUTION [249449]
|
Facility
|
IP
|
$3.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.44 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.78
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Senior |
$1.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.46
|
| Rate for Payer: Heritage Provider Network Senior |
$2.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: Multiplan Commercial |
$3.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.43
|
|
|
DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]
|
Facility
|
OP
|
$455.94
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.44 |
| Max. Negotiated Rate |
$480.79 |
| Rate for Payer: Adventist Health Commercial |
$91.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$281.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$480.79
|
| Rate for Payer: Blue Shield of California Commercial |
$248.68
|
| Rate for Payer: Blue Shield of California EPN |
$248.68
|
| Rate for Payer: Cash Price |
$205.17
|
| Rate for Payer: Cash Price |
$205.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$209.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$45.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$291.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$41.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$211.10
|
| Rate for Payer: Heritage Provider Network Senior |
$211.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$41.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$217.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$82.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$47.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$55.53
|
| Rate for Payer: Multiplan Commercial |
$341.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$182.38
|
| Rate for Payer: TriValley Medical Group Senior |
$182.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$164.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$150.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.58
|
| Rate for Payer: Vantage Medical Group Senior |
$45.58
|
|
|
DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]
|
Facility
|
IP
|
$455.94
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.53 |
| Max. Negotiated Rate |
$341.95 |
| Rate for Payer: Adventist Health Commercial |
$91.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$293.63
|
| Rate for Payer: Cash Price |
$205.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$209.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$246.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$211.10
|
| Rate for Payer: Heritage Provider Network Senior |
$211.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$82.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.98
|
| Rate for Payer: Multiplan Commercial |
$341.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$164.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$150.96
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]
|
Facility
|
IP
|
$329.11
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.57 |
| Max. Negotiated Rate |
$246.83 |
| Rate for Payer: Adventist Health Commercial |
$65.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$211.95
|
| Rate for Payer: Cash Price |
$148.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$177.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.38
|
| Rate for Payer: Heritage Provider Network Senior |
$152.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.28
|
| Rate for Payer: Multiplan Commercial |
$246.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$118.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$108.97
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]
|
Facility
|
OP
|
$329.11
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.44 |
| Max. Negotiated Rate |
$480.79 |
| Rate for Payer: Adventist Health Commercial |
$65.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$203.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$480.79
|
| Rate for Payer: Blue Shield of California Commercial |
$248.68
|
| Rate for Payer: Blue Shield of California EPN |
$248.68
|
| Rate for Payer: Cash Price |
$148.10
|
| Rate for Payer: Cash Price |
$148.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$45.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$210.63
|
| Rate for Payer: EPIC Health Plan Medicare |
$41.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.38
|
| Rate for Payer: Heritage Provider Network Senior |
$152.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$41.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$156.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$47.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$55.53
|
| Rate for Payer: Multiplan Commercial |
$246.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$131.64
|
| Rate for Payer: TriValley Medical Group Senior |
$131.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$118.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$108.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.58
|
| Rate for Payer: Vantage Medical Group Senior |
$45.58
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 0065041663
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 0065041663
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0065041622
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 0065806301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 0065806301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0065041622
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
DEXTRANOMER 50MG-HYALURONATE 15MG/ML(1)-0.9%SODCHL GEL IMPLANT SYRINGE [227990]
|
Facility
|
IP
|
$3,966.00
|
|
|
Service Code
|
HCPCS L8604
|
| Hospital Charge Code |
901700050
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$793.20 |
| Max. Negotiated Rate |
$13,808.00 |
| Rate for Payer: Adventist Health Commercial |
$793.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,554.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,808.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,594.33
|
| Rate for Payer: Blue Shield of California EPN |
$1,594.33
|
| Rate for Payer: Cash Price |
$1,784.70
|
| Rate for Payer: Cash Price |
$1,784.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,824.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,141.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,836.26
|
| Rate for Payer: Heritage Provider Network Senior |
$1,836.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,983.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,983.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,983.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$991.50
|
| Rate for Payer: Multiplan Commercial |
$2,974.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,432.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,313.14
|
|
