|
Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15576
|
| Min. Negotiated Rate |
$98.73 |
| 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 |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$98.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15574
|
| Min. Negotiated Rate |
$905.46 |
| 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 |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$905.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
|
IP
|
$11.15
|
|
|
Service Code
|
NDC 49502-605-95
|
| Hospital Charge Code |
NDG88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$8.36 |
| Rate for Payer: Adventist Health Commercial |
$2.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.66
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.55
|
| Rate for Payer: Heritage Provider Network Senior |
$7.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.79
|
| Rate for Payer: Multiplan Commercial |
$8.36
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
|
OP
|
$11.15
|
|
|
Service Code
|
NDC 49502-605-95
|
| Hospital Charge Code |
NDG88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$9.48 |
| Rate for Payer: Adventist Health Commercial |
$2.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.36
|
| Rate for Payer: Blue Shield of California Commercial |
$6.92
|
| Rate for Payer: Blue Shield of California EPN |
$6.55
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.48
|
| Rate for Payer: Dignity Health Senior |
$9.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.90
|
| Rate for Payer: Heritage Provider Network Senior |
$6.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.79
|
| Rate for Payer: Multiplan Commercial |
$8.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.46
|
| Rate for Payer: TriValley Medical Group Senior |
$4.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: Vantage Medical Group Senior |
$9.48
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
|
IP
|
$11.15
|
|
|
Service Code
|
NDC 49502-605-30
|
| Hospital Charge Code |
NDG88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$8.36 |
| Rate for Payer: Adventist Health Commercial |
$2.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.66
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.55
|
| Rate for Payer: Heritage Provider Network Senior |
$7.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.79
|
| Rate for Payer: Multiplan Commercial |
$8.36
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
|
OP
|
$11.15
|
|
|
Service Code
|
NDC 49502-605-30
|
| Hospital Charge Code |
NDG88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$9.48 |
| Rate for Payer: Adventist Health Commercial |
$2.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.36
|
| Rate for Payer: Blue Shield of California Commercial |
$6.92
|
| Rate for Payer: Blue Shield of California EPN |
$6.55
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.48
|
| Rate for Payer: Dignity Health Senior |
$9.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.90
|
| Rate for Payer: Heritage Provider Network Senior |
$6.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.79
|
| Rate for Payer: Multiplan Commercial |
$8.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.46
|
| Rate for Payer: TriValley Medical Group Senior |
$4.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: Vantage Medical Group Senior |
$9.48
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
IP
|
$401.56
|
|
|
Service Code
|
NDC 0006-3061-00
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.68 |
| Max. Negotiated Rate |
$301.17 |
| Rate for Payer: Adventist Health Commercial |
$80.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$275.87
|
| Rate for Payer: Cash Price |
$180.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$184.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$216.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$271.86
|
| Rate for Payer: Heritage Provider Network Senior |
$271.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.39
|
| Rate for Payer: Multiplan Commercial |
$301.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$146.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$134.16
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
NDC 71839-104-01
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.60 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Adventist Health Commercial |
$8.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.85
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.43
|
| Rate for Payer: Heritage Provider Network Senior |
$28.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.50
|
| Rate for Payer: Multiplan Commercial |
$31.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.03
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
OP
|
$401.56
|
|
|
Service Code
|
NDC 0006-3061-00
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.68 |
| Max. Negotiated Rate |
$341.33 |
| Rate for Payer: Adventist Health Commercial |
$80.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$214.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$275.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$341.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$220.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$301.17
|
| Rate for Payer: Blue Shield of California Commercial |
$249.37
|
| Rate for Payer: Blue Shield of California EPN |
$235.72
|
| Rate for Payer: Cash Price |
$180.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$184.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$341.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$341.33
|
| Rate for Payer: Dignity Health Senior |
$341.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$257.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$185.92
|
| Rate for Payer: Heritage Provider Network Senior |
$185.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$193.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.39
|
| Rate for Payer: Multiplan Commercial |
$301.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$160.62
|
| Rate for Payer: TriValley Medical Group Senior |
$160.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$146.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$134.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$341.33
|
| Rate for Payer: Vantage Medical Group Senior |
$341.33
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
OP
|
$401.56
|
|
|
Service Code
|
NDC 0006-3061-01
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.68 |
| Max. Negotiated Rate |
$341.33 |
| Rate for Payer: Adventist Health Commercial |
$80.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$214.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$275.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$341.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$220.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$301.17
|
| Rate for Payer: Blue Shield of California Commercial |
$249.37
|
| Rate for Payer: Blue Shield of California EPN |
$235.72
|
| Rate for Payer: Cash Price |
$180.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$184.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$341.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$341.33
|
| Rate for Payer: Dignity Health Senior |
$341.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$257.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$185.92
|
| Rate for Payer: Heritage Provider Network Senior |
$185.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$193.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.39
|
| Rate for Payer: Multiplan Commercial |
$301.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$160.62
|
| Rate for Payer: TriValley Medical Group Senior |
$160.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$146.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$134.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$341.33
|
| Rate for Payer: Vantage Medical Group Senior |
$341.33
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
IP
|
$401.56
|
|
|
Service Code
|
NDC 0006-3061-01
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.68 |
| Max. Negotiated Rate |
$301.17 |
| Rate for Payer: Adventist Health Commercial |
$80.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$275.87
|
| Rate for Payer: Cash Price |
$180.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$184.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$216.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$271.86
|
| Rate for Payer: Heritage Provider Network Senior |
$271.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.39
|
| Rate for Payer: Multiplan Commercial |
$301.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$146.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$134.16
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
NDC 71839-104-01
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.60 |
| Max. Negotiated Rate |
$35.70 |
| Rate for Payer: Adventist Health Commercial |
$8.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$35.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.50
|
| Rate for Payer: Blue Shield of California Commercial |
$26.08
|
| Rate for Payer: Blue Shield of California EPN |
$24.65
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.70
|
| Rate for Payer: Dignity Health Senior |
$35.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.45
|
| Rate for Payer: Heritage Provider Network Senior |
$19.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.50
|
| Rate for Payer: Multiplan Commercial |
$31.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.80
|
| Rate for Payer: TriValley Medical Group Senior |
$16.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.70
|
| Rate for Payer: Vantage Medical Group Senior |
$35.70
|
|
|
FOSCARNET 24 MG/ML INTRAVENOUS SOLUTION [10093]
|
Facility
|
IP
|
$2.27
|
|
|
Service Code
|
CPT J1455
|
| Hospital Charge Code |
1754909
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.76
|
|
|
FOSCARNET 24 MG/ML INTRAVENOUS SOLUTION [10093]
|
Facility
|
OP
|
$2.27
|
|
|
Service Code
|
CPT J1455
|
| Hospital Charge Code |
1754909
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$190.89 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$190.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$74.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$65.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$65.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$144.89
|
| Rate for Payer: Blue Shield of California Commercial |
$80.37
|
| Rate for Payer: Blue Shield of California EPN |
$80.37
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$65.31
|
| Rate for Payer: Dignity Health Senior |
$65.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$59.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1.05
|
| Rate for Payer: Humana Medicare |
$59.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$115.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$112.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$70.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74.80
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Senior |
$0.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$65.31
|
| Rate for Payer: Vantage Medical Group Senior |
$59.37
|
|
|
FOSCARNET INTRAVITREAL INJECTION 2400 MCG/0.1 ML [4081568]
|
Facility
|
OP
|
$2.30
|
|
|
Service Code
|
CPT J1455
|
| Hospital Charge Code |
1754909
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$190.89 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$190.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$74.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$65.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$65.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$144.89
|
| Rate for Payer: Blue Shield of California Commercial |
$80.37
|
| Rate for Payer: Blue Shield of California EPN |
$80.37
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$65.31
|
| Rate for Payer: Dignity Health Senior |
$65.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.47
|
| Rate for Payer: EPIC Health Plan Medicare |
$59.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.06
|
| Rate for Payer: Humana Medicare |
$59.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$115.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$112.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$70.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74.80
|
| Rate for Payer: Multiplan Commercial |
$1.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.92
|
| Rate for Payer: TriValley Medical Group Senior |
$0.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$65.31
|
| Rate for Payer: Vantage Medical Group Senior |
$59.37
|
|
|
FOSCARNET INTRAVITREAL INJECTION 2400 MCG/0.1 ML [4081568]
|
Facility
|
IP
|
$2.30
|
|
|
Service Code
|
CPT J1455
|
| Hospital Charge Code |
1754909
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.58
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.56
|
| Rate for Payer: Heritage Provider Network Senior |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.77
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$96.38
|
|
|
Service Code
|
NDC 70700-268-94
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.44 |
| Max. Negotiated Rate |
$72.28 |
| Rate for Payer: Adventist Health Commercial |
$19.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$66.21
|
| Rate for Payer: Cash Price |
$43.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.25
|
| Rate for Payer: Heritage Provider Network Senior |
$65.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.10
|
| Rate for Payer: Multiplan Commercial |
$72.28
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$96.38
|
|
|
Service Code
|
NDC 70700-268-94
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.44 |
| Max. Negotiated Rate |
$81.92 |
| Rate for Payer: Adventist Health Commercial |
$19.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$51.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$66.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$72.28
|
| Rate for Payer: Blue Shield of California Commercial |
$59.85
|
| Rate for Payer: Blue Shield of California EPN |
$56.58
|
| Rate for Payer: Cash Price |
$43.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$62.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.92
|
| Rate for Payer: Dignity Health Senior |
$81.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.66
|
| Rate for Payer: Heritage Provider Network Senior |
$59.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$46.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.10
|
| Rate for Payer: Multiplan Commercial |
$72.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$38.55
|
| Rate for Payer: TriValley Medical Group Senior |
$38.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.92
|
| Rate for Payer: Vantage Medical Group Senior |
$81.92
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$109.52
|
|
|
Service Code
|
NDC 0456-4300-08
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.82 |
| Max. Negotiated Rate |
$82.14 |
| Rate for Payer: Adventist Health Commercial |
$21.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$75.24
|
| Rate for Payer: Cash Price |
$49.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$59.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.15
|
| Rate for Payer: Heritage Provider Network Senior |
$74.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.38
|
| Rate for Payer: Multiplan Commercial |
$82.14
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$109.52
|
|
|
Service Code
|
NDC 0456-4300-08
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.82 |
| Max. Negotiated Rate |
$93.09 |
| Rate for Payer: Adventist Health Commercial |
$21.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$58.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$75.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$93.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$60.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$82.14
|
| Rate for Payer: Blue Shield of California Commercial |
$68.01
|
| Rate for Payer: Blue Shield of California EPN |
$64.29
|
| Rate for Payer: Cash Price |
$49.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$71.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$93.09
|
| Rate for Payer: Dignity Health Senior |
$93.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$67.79
|
| Rate for Payer: Heritage Provider Network Senior |
$67.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$52.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.38
|
| Rate for Payer: Multiplan Commercial |
$82.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.81
|
| Rate for Payer: TriValley Medical Group Senior |
$43.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$93.09
|
| Rate for Payer: Vantage Medical Group Senior |
$93.09
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$109.52
|
|
|
Service Code
|
NDC 0456-4300-01
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.82 |
| Max. Negotiated Rate |
$82.14 |
| Rate for Payer: Adventist Health Commercial |
$21.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$75.24
|
| Rate for Payer: Cash Price |
$49.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$59.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.15
|
| Rate for Payer: Heritage Provider Network Senior |
$74.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.38
|
| Rate for Payer: Multiplan Commercial |
$82.14
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$83.76
|
|
|
Service Code
|
NDC 67877-749-57
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.16 |
| Max. Negotiated Rate |
$62.82 |
| Rate for Payer: Adventist Health Commercial |
$16.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$57.54
|
| Rate for Payer: Cash Price |
$37.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$56.71
|
| Rate for Payer: Heritage Provider Network Senior |
$56.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.94
|
| Rate for Payer: Multiplan Commercial |
$62.82
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$109.52
|
|
|
Service Code
|
NDC 0456-4300-01
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.82 |
| Max. Negotiated Rate |
$93.09 |
| Rate for Payer: Adventist Health Commercial |
$21.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$58.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$75.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$93.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$60.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$82.14
|
| Rate for Payer: Blue Shield of California Commercial |
$68.01
|
| Rate for Payer: Blue Shield of California EPN |
$64.29
|
| Rate for Payer: Cash Price |
$49.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$71.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$93.09
|
| Rate for Payer: Dignity Health Senior |
$93.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$67.79
|
| Rate for Payer: Heritage Provider Network Senior |
$67.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$52.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.38
|
| Rate for Payer: Multiplan Commercial |
$82.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.81
|
| Rate for Payer: TriValley Medical Group Senior |
$43.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$93.09
|
| Rate for Payer: Vantage Medical Group Senior |
$93.09
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$96.38
|
|
|
Service Code
|
NDC 70700-268-99
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.44 |
| Max. Negotiated Rate |
$81.92 |
| Rate for Payer: Adventist Health Commercial |
$19.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$51.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$66.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$72.28
|
| Rate for Payer: Blue Shield of California Commercial |
$59.85
|
| Rate for Payer: Blue Shield of California EPN |
$56.58
|
| Rate for Payer: Cash Price |
$43.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$62.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.92
|
| Rate for Payer: Dignity Health Senior |
$81.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.66
|
| Rate for Payer: Heritage Provider Network Senior |
$59.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$46.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.10
|
| Rate for Payer: Multiplan Commercial |
$72.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$38.55
|
| Rate for Payer: TriValley Medical Group Senior |
$38.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.92
|
| Rate for Payer: Vantage Medical Group Senior |
$81.92
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$96.38
|
|
|
Service Code
|
NDC 70700-268-99
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.44 |
| Max. Negotiated Rate |
$72.28 |
| Rate for Payer: Adventist Health Commercial |
$19.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$66.21
|
| Rate for Payer: Cash Price |
$43.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.25
|
| Rate for Payer: Heritage Provider Network Senior |
$65.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.10
|
| Rate for Payer: Multiplan Commercial |
$72.28
|
|
