|
GEMCITABINE 200 MG INTRAVENOUS SOLUTION [17121]
|
Facility
|
IP
|
$11.03
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
1755759
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$8.27 |
| Rate for Payer: Adventist Health Commercial |
$2.21
|
| Rate for Payer: Adventist Health Commercial |
$3.60
|
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Adventist Health Commercial |
$2.89
|
| Rate for Payer: Adventist Health Commercial |
$2.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.89
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Cash Price |
$5.49
|
| Rate for Payer: Cash Price |
$6.51
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$4.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.25
|
| Rate for Payer: Heritage Provider Network Senior |
$9.75
|
| Rate for Payer: Heritage Provider Network Senior |
$7.47
|
| Rate for Payer: Heritage Provider Network Senior |
$8.25
|
| Rate for Payer: Heritage Provider Network Senior |
$9.79
|
| Rate for Payer: Heritage Provider Network Senior |
$12.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$10.84
|
| Rate for Payer: Multiplan Commercial |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$10.80
|
| Rate for Payer: Multiplan Commercial |
$9.14
|
| Rate for Payer: Multiplan Commercial |
$8.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.01
|
|
|
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION [191076]
|
Facility
|
OP
|
$1.76
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
NDG191076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$226.89 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$226.89
|
| Rate for Payer: Blue Shield of California Commercial |
$10.21
|
| Rate for Payer: Blue Shield of California EPN |
$10.21
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.50
|
| Rate for Payer: Dignity Health Senior |
$1.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$1.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Senior |
$0.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.50
|
| Rate for Payer: Vantage Medical Group Senior |
$1.50
|
|
|
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION [191076]
|
Facility
|
IP
|
$1.76
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
NDG191076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.21
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Senior |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$1.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.59
|
|
|
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION [105417]
|
Facility
|
IP
|
$136.18
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
ERX105417
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.65 |
| Max. Negotiated Rate |
$102.14 |
| Rate for Payer: Adventist Health Commercial |
$27.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$93.56
|
| Rate for Payer: Cash Price |
$61.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$62.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.19
|
| Rate for Payer: Heritage Provider Network Senior |
$92.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.04
|
| Rate for Payer: Multiplan Commercial |
$102.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$49.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$45.50
|
|
|
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION [105417]
|
Facility
|
OP
|
$136.18
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
ERX105417
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$226.89 |
| Rate for Payer: Adventist Health Commercial |
$27.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$93.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$115.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$74.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$102.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$226.89
|
| Rate for Payer: Blue Shield of California Commercial |
$10.21
|
| Rate for Payer: Blue Shield of California EPN |
$10.21
|
| Rate for Payer: Cash Price |
$61.28
|
| Rate for Payer: Cash Price |
$61.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$62.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$115.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$115.75
|
| Rate for Payer: Dignity Health Senior |
$115.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$87.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$63.05
|
| Rate for Payer: Heritage Provider Network Senior |
$63.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$65.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.04
|
| Rate for Payer: Multiplan Commercial |
$102.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$54.47
|
| Rate for Payer: TriValley Medical Group Senior |
$54.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$49.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$45.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$115.75
|
| Rate for Payer: Vantage Medical Group Senior |
$115.75
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 65862-624-60
|
| Hospital Charge Code |
1711318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 60687-224-11
|
| Hospital Charge Code |
1711318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| 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: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| 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 Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| 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 Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| 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: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 65862-624-60
|
| Hospital Charge Code |
1711318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 69097-821-03
|
| Hospital Charge Code |
1711318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 60687-224-01
|
| Hospital Charge Code |
1711318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 60687-224-11
|
| Hospital Charge Code |
1711318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 60687-224-01
|
| Hospital Charge Code |
1711318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| 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: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| 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 Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| 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 Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| 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: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 69097-821-03
|
| Hospital Charge Code |
1711318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN [219685]
|
Facility
|
IP
|
$11,527.46
|
|
|
Service Code
|
CPT J9203
|
| Hospital Charge Code |
1755680
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,086.47 |
| Max. Negotiated Rate |
$8,645.60 |
| Rate for Payer: Adventist Health Commercial |
$2,305.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,919.37
|
| Rate for Payer: Cash Price |
$5,187.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,302.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,224.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,804.09
|
| Rate for Payer: Heritage Provider Network Senior |
$7,804.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,086.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,881.86
|
| Rate for Payer: Multiplan Commercial |
$8,645.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,202.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,851.32
|
|
|
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN [219685]
|
Facility
|
OP
|
$11,527.46
|
|
|
Service Code
|
CPT J9203
|
| Hospital Charge Code |
1755680
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$209.29 |
| Max. Negotiated Rate |
$8,645.60 |
| Rate for Payer: Adventist Health Commercial |
$2,305.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$445.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,919.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$282.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$248.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$248.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$389.37
|
| Rate for Payer: Blue Shield of California Commercial |
$209.29
|
| Rate for Payer: Blue Shield of California EPN |
$209.29
|
| Rate for Payer: Cash Price |
$5,187.36
|
| Rate for Payer: Cash Price |
$5,187.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,302.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$339.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$248.91
|
| Rate for Payer: Dignity Health Senior |
$248.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,377.57
|
| Rate for Payer: EPIC Health Plan Medicare |
$226.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,337.21
|
| Rate for Payer: Heritage Provider Network Senior |
$5,337.21
|
| Rate for Payer: Humana Medicare |
$226.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$359.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$226.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$429.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,086.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$267.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,881.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$285.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$285.11
|
| Rate for Payer: Multiplan Commercial |
$8,645.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,610.98
|
| Rate for Payer: TriValley Medical Group Senior |
$4,610.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,202.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,851.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$339.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$248.91
|
| Rate for Payer: Vantage Medical Group Senior |
$226.28
|
|
|
Genioplasty; sliding osteotomy, single piece
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 21121
|
| Min. Negotiated Rate |
$209.09 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,424.96
|
| Rate for Payer: Dignity Health Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,022.69
|
| Rate for Payer: Humana Medicare |
$4,022.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$209.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,022.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,643.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,746.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,068.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,068.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,424.96
|
| Rate for Payer: TriValley Medical Group Senior |
$4,022.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
GENTAMICIN 0.1 % TOPICAL CREAM [3423]
|
Facility
|
IP
|
$3.16
|
|
|
Service Code
|
NDC 0713-0683-31
|
| Hospital Charge Code |
NDG3423
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.17
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Senior |
$2.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
|
|
GENTAMICIN 0.1 % TOPICAL CREAM [3423]
|
Facility
|
OP
|
$3.16
|
|
|
Service Code
|
NDC 0713-0683-15
|
| Hospital Charge Code |
1743212
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.69
|
| Rate for Payer: Dignity Health Senior |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Senior |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.26
|
| Rate for Payer: TriValley Medical Group Senior |
$1.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.69
|
| Rate for Payer: Vantage Medical Group Senior |
$2.69
|
|
|
GENTAMICIN 0.1 % TOPICAL CREAM [3423]
|
Facility
|
IP
|
$3.16
|
|
|
Service Code
|
NDC 45802-056-35
|
| Hospital Charge Code |
1743212
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.17
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Senior |
$2.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
|
|
GENTAMICIN 0.1 % TOPICAL CREAM [3423]
|
Facility
|
OP
|
$3.16
|
|
|
Service Code
|
NDC 45802-056-35
|
| Hospital Charge Code |
1743212
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.69
|
| Rate for Payer: Dignity Health Senior |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Senior |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.26
|
| Rate for Payer: TriValley Medical Group Senior |
$1.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.69
|
| Rate for Payer: Vantage Medical Group Senior |
$2.69
|
|
|
GENTAMICIN 0.1 % TOPICAL CREAM [3423]
|
Facility
|
OP
|
$3.16
|
|
|
Service Code
|
NDC 0713-0683-31
|
| Hospital Charge Code |
NDG3423
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.69
|
| Rate for Payer: Dignity Health Senior |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Senior |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.26
|
| Rate for Payer: TriValley Medical Group Senior |
$1.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.69
|
| Rate for Payer: Vantage Medical Group Senior |
$2.69
|
|
|
GENTAMICIN 0.1 % TOPICAL CREAM [3423]
|
Facility
|
IP
|
$3.16
|
|
|
Service Code
|
NDC 0713-0683-15
|
| Hospital Charge Code |
1743212
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.17
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Senior |
$2.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
|
|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
IP
|
$3.16
|
|
|
Service Code
|
NDC 45802-046-35
|
| Hospital Charge Code |
1743222
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.17
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Senior |
$2.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
|
|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
IP
|
$2.80
|
|
|
Service Code
|
NDC 52565-090-30
|
| Hospital Charge Code |
NDG3424
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.10 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.92
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.90
|
| Rate for Payer: Heritage Provider Network Senior |
$1.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$2.10
|
|
|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
OP
|
$3.16
|
|
|
Service Code
|
NDC 52565-090-15
|
| Hospital Charge Code |
1743222
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.69
|
| Rate for Payer: Dignity Health Senior |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Senior |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.26
|
| Rate for Payer: TriValley Medical Group Senior |
$1.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.69
|
| Rate for Payer: Vantage Medical Group Senior |
$2.69
|
|
