|
EVEROLIMUS 0.3 MG/ML SPECIAL DILUTION (FROM 0.75 MG TAB) [4081261]
|
Facility
|
IP
|
$39.52
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$29.64 |
| Rate for Payer: Adventist Health Commercial |
$7.90
|
| Rate for Payer: Cash Price |
$21.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.30
|
| Rate for Payer: Heritage Provider Network Senior |
$18.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.88
|
| Rate for Payer: Multiplan Commercial |
$29.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.09
|
|
|
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.25 MG TABLET [104555]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$10.79 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Adventist Health Commercial |
$2.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.79
|
| Rate for Payer: Blue Shield of California Commercial |
$4.25
|
| Rate for Payer: Blue Shield of California Commercial |
$4.25
|
| Rate for Payer: Blue Shield of California EPN |
$4.25
|
| Rate for Payer: Blue Shield of California EPN |
$4.25
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cash Price |
$7.24
|
| Rate for Payer: Cash Price |
$7.24
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: Dignity Health Senior |
$11.19
|
| Rate for Payer: Dignity Health Senior |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.09
|
| Rate for Payer: Heritage Provider Network Senior |
$6.09
|
| Rate for Payer: Heritage Provider Network Senior |
$1.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: Multiplan Commercial |
$9.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.26
|
| Rate for Payer: TriValley Medical Group Senior |
$5.26
|
| Rate for Payer: TriValley Medical Group Senior |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$11.19
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.25 MG TABLET [104555]
|
Facility
|
IP
|
$13.16
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$9.87 |
| Rate for Payer: Adventist Health Commercial |
$2.63
|
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cash Price |
$7.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.09
|
| Rate for Payer: Heritage Provider Network Senior |
$6.09
|
| Rate for Payer: Heritage Provider Network Senior |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.29
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: Multiplan Commercial |
$9.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.36
|
|
|
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.5 MG TABLET [104877]
|
Facility
|
OP
|
$26.32
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$22.37 |
| Rate for Payer: Adventist Health Commercial |
$5.26
|
| Rate for Payer: Adventist Health Commercial |
$5.27
|
| Rate for Payer: Adventist Health Commercial |
$1.97
|
| Rate for Payer: Adventist Health Commercial |
$3.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.79
|
| Rate for Payer: Blue Shield of California Commercial |
$4.25
|
| Rate for Payer: Blue Shield of California Commercial |
$4.25
|
| Rate for Payer: Blue Shield of California Commercial |
$4.25
|
| Rate for Payer: Blue Shield of California Commercial |
$4.25
|
| Rate for Payer: Blue Shield of California EPN |
$4.25
|
| Rate for Payer: Blue Shield of California EPN |
$4.25
|
| Rate for Payer: Blue Shield of California EPN |
$4.25
|
| Rate for Payer: Blue Shield of California EPN |
$4.25
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: Cash Price |
$10.47
|
| Rate for Payer: Cash Price |
$14.47
|
| Rate for Payer: Cash Price |
$14.47
|
| Rate for Payer: Cash Price |
$10.47
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: Cash Price |
$14.50
|
| Rate for Payer: Cash Price |
$14.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.41
|
| Rate for Payer: Dignity Health Senior |
$22.41
|
| Rate for Payer: Dignity Health Senior |
$8.36
|
| Rate for Payer: Dignity Health Senior |
$22.37
|
| Rate for Payer: Dignity Health Senior |
$16.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.56
|
| Rate for Payer: Heritage Provider Network Senior |
$4.56
|
| Rate for Payer: Heritage Provider Network Senior |
$8.81
|
| Rate for Payer: Heritage Provider Network Senior |
$12.19
|
| Rate for Payer: Heritage Provider Network Senior |
$12.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.89
|
| Rate for Payer: Multiplan Commercial |
$7.38
|
| Rate for Payer: Multiplan Commercial |
$19.74
|
| Rate for Payer: Multiplan Commercial |
$19.77
|
| Rate for Payer: Multiplan Commercial |
$14.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.53
|
| Rate for Payer: TriValley Medical Group Senior |
$3.94
|
| Rate for Payer: TriValley Medical Group Senior |
$10.53
|
| Rate for Payer: TriValley Medical Group Senior |
$7.61
|
| Rate for Payer: TriValley Medical Group Senior |
$10.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.36
|
| Rate for Payer: Vantage Medical Group Senior |
$16.18
|
| Rate for Payer: Vantage Medical Group Senior |
$22.37
|
| Rate for Payer: Vantage Medical Group Senior |
$22.41
|
| Rate for Payer: Vantage Medical Group Senior |
$8.36
|
|
|
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.5 MG TABLET [104877]
|
Facility
|
IP
|
$26.36
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.77 |
| Max. Negotiated Rate |
$19.77 |
| Rate for Payer: Adventist Health Commercial |
$5.27
|
| Rate for Payer: Adventist Health Commercial |
$1.97
|
| Rate for Payer: Adventist Health Commercial |
$3.81
|
| Rate for Payer: Adventist Health Commercial |
$5.26
|
| Rate for Payer: Cash Price |
$14.47
|
| Rate for Payer: Cash Price |
$14.50
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: Cash Price |
$10.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.81
|
| Rate for Payer: Heritage Provider Network Senior |
$4.56
|
| Rate for Payer: Heritage Provider Network Senior |
$8.81
|
| Rate for Payer: Heritage Provider Network Senior |
$12.19
|
| Rate for Payer: Heritage Provider Network Senior |
$12.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.76
|
| Rate for Payer: Multiplan Commercial |
$14.27
|
| Rate for Payer: Multiplan Commercial |
$7.38
|
| Rate for Payer: Multiplan Commercial |
$19.77
|
| Rate for Payer: Multiplan Commercial |
$19.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.30
|
|
|
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.75 MG TABLET [104556]
|
Facility
|
IP
|
$39.52
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$29.64 |
| Rate for Payer: Adventist Health Commercial |
$7.90
|
| Rate for Payer: Cash Price |
$21.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.30
|
| Rate for Payer: Heritage Provider Network Senior |
$18.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.88
|
| Rate for Payer: Multiplan Commercial |
$29.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.09
|
|
|
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.75 MG TABLET [104556]
|
Facility
|
OP
|
$39.52
|
|
|
Service Code
|
HCPCS J7527
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$33.59 |
| Rate for Payer: Adventist Health Commercial |
$7.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$21.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$29.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.79
|
| Rate for Payer: Blue Shield of California Commercial |
$4.25
|
| Rate for Payer: Blue Shield of California EPN |
$4.25
|
| Rate for Payer: Cash Price |
$21.73
|
| Rate for Payer: Cash Price |
$21.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.59
|
| Rate for Payer: Dignity Health Senior |
$33.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.30
|
| Rate for Payer: Heritage Provider Network Senior |
$18.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$27.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$27.66
|
| Rate for Payer: Multiplan Commercial |
$29.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.81
|
| Rate for Payer: TriValley Medical Group Senior |
$15.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.59
|
| Rate for Payer: Vantage Medical Group Senior |
$33.59
|
|
|
EXEMESTANE 25 MG TABLET [26551]
|
Facility
|
IP
|
$46.05
|
|
|
Service Code
|
NDC 0009-7663-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$34.54 |
| Rate for Payer: Adventist Health Commercial |
$9.21
|
| Rate for Payer: Cash Price |
$25.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.18
|
| Rate for Payer: Heritage Provider Network Senior |
$31.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.51
|
| Rate for Payer: Multiplan Commercial |
$34.54
|
|
|
EXEMESTANE 25 MG TABLET [26551]
|
Facility
|
IP
|
$13.03
|
|
|
Service Code
|
NDC 0054-0080-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$9.77 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.82
|
| Rate for Payer: Heritage Provider Network Senior |
$8.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.77
|
|
|
EXEMESTANE 25 MG TABLET [26551]
|
Facility
|
OP
|
$13.03
|
|
|
Service Code
|
NDC 0054-0080-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$11.08 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.77
|
| Rate for Payer: Blue Shield of California Commercial |
$7.95
|
| Rate for Payer: Blue Shield of California EPN |
$6.36
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.08
|
| Rate for Payer: Dignity Health Senior |
$11.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.07
|
| Rate for Payer: Heritage Provider Network Senior |
$8.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.12
|
| Rate for Payer: Multiplan Commercial |
$9.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.21
|
| Rate for Payer: TriValley Medical Group Senior |
$5.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.08
|
| Rate for Payer: Vantage Medical Group Senior |
$11.08
|
|
|
EXEMESTANE 25 MG TABLET [26551]
|
Facility
|
OP
|
$46.05
|
|
|
Service Code
|
NDC 0009-7663-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$39.14 |
| Rate for Payer: Adventist Health Commercial |
$9.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.54
|
| Rate for Payer: Blue Shield of California Commercial |
$28.09
|
| Rate for Payer: Blue Shield of California EPN |
$22.47
|
| Rate for Payer: Cash Price |
$25.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.14
|
| Rate for Payer: Dignity Health Senior |
$39.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.50
|
| Rate for Payer: Heritage Provider Network Senior |
$28.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.23
|
| Rate for Payer: Multiplan Commercial |
$34.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.42
|
| Rate for Payer: TriValley Medical Group Senior |
$18.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.14
|
| Rate for Payer: Vantage Medical Group Senior |
$39.14
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 59651-052-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| 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 Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| 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 |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 67877-490-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 59651-052-90
|
| 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: Cash Price |
$0.18
|
| 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 Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 67877-490-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 59651-052-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 59651-052-90
|
| 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 Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| 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: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.18
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.16
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.23
|
| Rate for Payer: Molina Healthcare of CA 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
|
|
|
FACTOR XIII 1,000 UNIT-1,600 UNIT INTRAVENOUS SOLUTION [108721]
|
Facility
|
IP
|
$15.34
|
|
|
Service Code
|
HCPCS J7180
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$11.51 |
| Rate for Payer: Adventist Health Commercial |
$3.07
|
| Rate for Payer: Cash Price |
$8.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.10
|
| Rate for Payer: Heritage Provider Network Senior |
$7.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.83
|
| Rate for Payer: Multiplan Commercial |
$11.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.08
|
|
|
FACTOR XIII 1,000 UNIT-1,600 UNIT INTRAVENOUS SOLUTION [108721]
|
Facility
|
OP
|
$15.34
|
|
|
Service Code
|
HCPCS J7180
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$33.11 |
| Rate for Payer: Adventist Health Commercial |
$3.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.11
|
| Rate for Payer: Blue Shield of California Commercial |
$12.66
|
| Rate for Payer: Blue Shield of California EPN |
$12.66
|
| Rate for Payer: Cash Price |
$8.43
|
| Rate for Payer: Cash Price |
$8.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.86
|
| Rate for Payer: Dignity Health Senior |
$11.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.82
|
| Rate for Payer: EPIC Health Plan Medicare |
$10.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.10
|
| Rate for Payer: Heritage Provider Network Senior |
$7.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.58
|
| Rate for Payer: Multiplan Commercial |
$11.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.14
|
| Rate for Payer: TriValley Medical Group Senior |
$6.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.86
|
| Rate for Payer: Vantage Medical Group Senior |
$11.86
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 31722-708-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 60687-103-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
OP
|
$2.75
|
|
|
Service Code
|
NDC 60687-103-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.06
|
| Rate for Payer: Blue Shield of California Commercial |
$1.68
|
| Rate for Payer: Blue Shield of California EPN |
$1.34
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.34
|
| Rate for Payer: Dignity Health Senior |
$2.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.70
|
| Rate for Payer: Heritage Provider Network Senior |
$1.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.93
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.10
|
| Rate for Payer: TriValley Medical Group Senior |
$1.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2.34
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 33342-026-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 31722-708-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Senior |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 60687-103-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
|
