|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
OP
|
$50.40
|
|
|
Service Code
|
HCPCS J1453
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$42.84 |
| Rate for Payer: Adventist Health Commercial |
$10.08
|
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Adventist Health Commercial |
$19.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$60.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$83.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$54.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$73.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.93
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$22.68
|
| Rate for Payer: Cash Price |
$44.38
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cash Price |
$44.38
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$22.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$45.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$83.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$83.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$25.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$40.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$83.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$28.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$42.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$45.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.34
|
| Rate for Payer: Heritage Provider Network Senior |
$23.34
|
| Rate for Payer: Heritage Provider Network Senior |
$22.22
|
| Rate for Payer: Heritage Provider Network Senior |
$45.66
|
| Rate for Payer: Heritage Provider Network Senior |
$15.56
|
| Rate for Payer: Heritage Provider Network Senior |
$13.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$16.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$22.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$47.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$24.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$33.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$35.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$69.03
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: Multiplan Commercial |
$37.80
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$73.97
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$20.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$39.45
|
| Rate for Payer: TriValley Medical Group Senior |
$12.00
|
| Rate for Payer: TriValley Medical Group Senior |
$13.44
|
| Rate for Payer: TriValley Medical Group Senior |
$20.16
|
| Rate for Payer: TriValley Medical Group Senior |
$19.20
|
| Rate for Payer: TriValley Medical Group Senior |
$39.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$35.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$32.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$83.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$83.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.50
|
| Rate for Payer: Vantage Medical Group Senior |
$83.83
|
| Rate for Payer: Vantage Medical Group Senior |
$25.50
|
| Rate for Payer: Vantage Medical Group Senior |
$42.84
|
| Rate for Payer: Vantage Medical Group Senior |
$28.56
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J1453
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Adventist Health Commercial |
$19.72
|
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Adventist Health Commercial |
$10.08
|
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$63.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.91
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$22.68
|
| Rate for Payer: Cash Price |
$44.38
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$45.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$45.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.56
|
| Rate for Payer: Heritage Provider Network Senior |
$22.22
|
| Rate for Payer: Heritage Provider Network Senior |
$13.89
|
| Rate for Payer: Heritage Provider Network Senior |
$15.56
|
| Rate for Payer: Heritage Provider Network Senior |
$23.34
|
| Rate for Payer: Heritage Provider Network Senior |
$45.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$37.80
|
| Rate for Payer: Multiplan Commercial |
$73.97
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$35.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$32.65
|
|
|
FOSCARNET 24 MG/ML INTRAVENOUS SOLUTION [10093]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
HCPCS J1455
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.35
|
| Rate for Payer: Blue Shield of California Commercial |
$66.77
|
| Rate for Payer: Blue Shield of California Commercial |
$66.77
|
| Rate for Payer: Blue Shield of California Commercial |
$66.77
|
| Rate for Payer: Blue Shield of California EPN |
$66.77
|
| Rate for Payer: Blue Shield of California EPN |
$66.77
|
| Rate for Payer: Blue Shield of California EPN |
$66.77
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.93
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$1.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Senior |
$0.91
|
| Rate for Payer: TriValley Medical Group Senior |
$0.69
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.47
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.47
|
|
|
FOSCARNET 24 MG/ML INTRAVENOUS SOLUTION [10093]
|
Facility
|
IP
|
$2.27
|
|
|
Service Code
|
HCPCS J1455
|
| Hospital Charge Code |
901700025
|
|
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: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$1.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.57
|
|
|
FOSCARNET INTRAVITREAL INJECTION 2400 MCG/0.1 ML [4081568]
|
Facility
|
OP
|
$2.30
|
|
|
Service Code
|
HCPCS J1455
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.35
|
| Rate for Payer: Blue Shield of California Commercial |
$66.77
|
| Rate for Payer: Blue Shield of California EPN |
$66.77
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.61
|
| Rate for Payer: Multiplan Commercial |
$1.73
|
| 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 |
$0.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.96
|
| Rate for Payer: Vantage Medical Group Senior |
$1.96
|
|
|
FOSCARNET INTRAVITREAL INJECTION 2400 MCG/0.1 ML [4081568]
|
Facility
|
IP
|
$2.30
|
|
|
Service Code
|
HCPCS J1455
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.48
|
| Rate for Payer: Cash Price |
$1.03
|
| 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 |
$1.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.76
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$96.38
|
|
|
Service Code
|
NDC 7070026894
|
| Hospital Charge Code |
901700029
|
|
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 Non-Gatekeeper |
$59.56
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$48.21
|
| Rate for Payer: Blue Shield of California Commercial |
$58.79
|
| Rate for Payer: Blue Shield of California EPN |
$47.03
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$45.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$67.47
|
| 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: United Healthcare All Other HMO/non HMO |
$48.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$48.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$81.92
|
| 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 7070026899
|
| Hospital Charge Code |
901700029
|
|
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 |
$62.07
|
| 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 Foundation Hospitals Medi-Cal |
$17.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.09
|
| Rate for Payer: Multiplan Commercial |
$72.28
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$83.76
|
|
|
Service Code
|
NDC 6787774957
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.16 |
| Max. Negotiated Rate |
$71.20 |
| Rate for Payer: Adventist Health Commercial |
$16.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$71.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$62.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$41.90
|
| Rate for Payer: Blue Shield of California Commercial |
$51.09
|
| Rate for Payer: Blue Shield of California EPN |
$40.87
|
| Rate for Payer: Cash Price |
$37.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$71.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.85
|
| Rate for Payer: Heritage Provider Network Senior |
$51.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$39.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$58.63
|
| Rate for Payer: Multiplan Commercial |
$62.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$33.50
|
| Rate for Payer: TriValley Medical Group Senior |
$33.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$41.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$71.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.20
|
| Rate for Payer: Vantage Medical Group Senior |
$71.20
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$96.38
|
|
|
Service Code
|
NDC 7070026899
|
| Hospital Charge Code |
901700029
|
|
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 Non-Gatekeeper |
$59.56
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$48.21
|
| Rate for Payer: Blue Shield of California Commercial |
$58.79
|
| Rate for Payer: Blue Shield of California EPN |
$47.03
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$45.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$67.47
|
| 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: United Healthcare All Other HMO/non HMO |
$48.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$48.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$81.92
|
| 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
|
$83.76
|
|
|
Service Code
|
NDC 6787774957
|
| Hospital Charge Code |
901700029
|
|
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 |
$53.94
|
| 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 Foundation Hospitals 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
|
IP
|
$96.38
|
|
|
Service Code
|
NDC 7070026894
|
| Hospital Charge Code |
901700029
|
|
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 |
$62.07
|
| 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 Foundation Hospitals Medi-Cal |
$17.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.09
|
| Rate for Payer: Multiplan Commercial |
$72.28
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION [88011]
|
Facility
|
OP
|
$3.28
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Adventist Health Commercial |
$4.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.05
|
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.53
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.67
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.23
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Heritage Provider Network Senior |
$11.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Multiplan Commercial |
$18.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.31
|
| Rate for Payer: TriValley Medical Group Senior |
$9.70
|
| Rate for Payer: TriValley Medical Group Senior |
$1.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION [88011]
|
Facility
|
IP
|
$24.26
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.39 |
| Max. Negotiated Rate |
$18.20 |
| Rate for Payer: Adventist Health Commercial |
$4.85
|
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.62
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Heritage Provider Network Senior |
$11.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Multiplan Commercial |
$18.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.03
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION [88010]
|
Facility
|
IP
|
$14.56
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Adventist Health Commercial |
$2.91
|
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.38
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cash Price |
$6.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1.28
|
| Rate for Payer: Heritage Provider Network Senior |
$6.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: Multiplan Commercial |
$10.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.82
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION [88010]
|
Facility
|
OP
|
$2.77
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Adventist Health Commercial |
$2.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.05
|
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cash Price |
$6.55
|
| Rate for Payer: Cash Price |
$6.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.67
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.74
|
| Rate for Payer: Heritage Provider Network Senior |
$1.28
|
| Rate for Payer: Heritage Provider Network Senior |
$6.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: Multiplan Commercial |
$10.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.11
|
| Rate for Payer: TriValley Medical Group Senior |
$5.82
|
| Rate for Payer: TriValley Medical Group Senior |
$1.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
|
|
FOSPHENYTOIN 50 MG PE/ML IV INJECTION SOLUTION WRAP [408056880]
|
Facility
|
OP
|
$24.26
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Adventist Health Commercial |
$4.85
|
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Adventist Health Commercial |
$2.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.05
|
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cash Price |
$6.55
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: Cash Price |
$6.55
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.53
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.67
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.67
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.74
|
| Rate for Payer: Heritage Provider Network Senior |
$6.74
|
| Rate for Payer: Heritage Provider Network Senior |
$11.23
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$18.20
|
| Rate for Payer: Multiplan Commercial |
$10.92
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.82
|
| Rate for Payer: TriValley Medical Group Senior |
$9.70
|
| Rate for Payer: TriValley Medical Group Senior |
$1.31
|
| Rate for Payer: TriValley Medical Group Senior |
$5.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
|
|
FOSPHENYTOIN 50 MG PE/ML IV INJECTION SOLUTION WRAP [408056880]
|
Facility
|
IP
|
$3.28
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.46 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Adventist Health Commercial |
$2.91
|
| Rate for Payer: Adventist Health Commercial |
$4.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.38
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: Cash Price |
$6.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.23
|
| Rate for Payer: Heritage Provider Network Senior |
$11.23
|
| Rate for Payer: Heritage Provider Network Senior |
$6.74
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Multiplan Commercial |
$10.92
|
| Rate for Payer: Multiplan Commercial |
$18.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.03
|
|
|
FRACTURES OF FEMUR WITH MCC
|
Facility
|
IP
|
$24,774.38
|
|
|
Service Code
|
MSDRG 533
|
| Min. Negotiated Rate |
$18,488.34 |
| Max. Negotiated Rate |
$24,774.38 |
| Rate for Payer: EPIC Health Plan Medicare |
$18,488.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18,488.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21,261.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24,774.38
|
|
|
FRACTURES OF FEMUR WITHOUT MCC
|
Facility
|
IP
|
$13,079.65
|
|
|
Service Code
|
MSDRG 534
|
| Min. Negotiated Rate |
$9,760.93 |
| Max. Negotiated Rate |
$13,079.65 |
| Rate for Payer: EPIC Health Plan Medicare |
$9,760.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9,760.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11,225.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13,079.65
|
|
|
FRACTURES OF HIP AND PELVIS WITH MCC
|
Facility
|
IP
|
$20,387.32
|
|
|
Service Code
|
MSDRG 535
|
| Min. Negotiated Rate |
$15,214.42 |
| Max. Negotiated Rate |
$20,387.32 |
| Rate for Payer: EPIC Health Plan Medicare |
$15,214.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15,214.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17,496.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20,387.32
|
|
|
FRACTURES OF HIP AND PELVIS WITHOUT MCC
|
Facility
|
IP
|
$13,102.68
|
|
|
Service Code
|
MSDRG 536
|
| Min. Negotiated Rate |
$9,778.12 |
| Max. Negotiated Rate |
$13,102.68 |
| Rate for Payer: EPIC Health Plan Medicare |
$9,778.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9,778.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11,244.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13,102.68
|
|
|
FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC
|
Facility
|
IP
|
$22,580.07
|
|
|
Service Code
|
MSDRG 562
|
| Min. Negotiated Rate |
$16,850.80 |
| Max. Negotiated Rate |
$22,580.07 |
| Rate for Payer: EPIC Health Plan Medicare |
$16,850.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16,850.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19,378.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22,580.07
|
|
|
FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC
|
Facility
|
IP
|
$14,452.41
|
|
|
Service Code
|
MSDRG 563
|
| Min. Negotiated Rate |
$10,785.38 |
| Max. Negotiated Rate |
$14,452.41 |
| Rate for Payer: EPIC Health Plan Medicare |
$10,785.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10,785.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$12,403.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$14,452.41
|
|
|
FULL TERM NEONATE WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$64,727.74
|
|
|
Service Code
|
MSDRG 793
|
| Min. Negotiated Rate |
$4,780.00 |
| Max. Negotiated Rate |
$64,727.74 |
| Rate for Payer: EPIC Health Plan Medicare |
$48,304.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48,304.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$55,549.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$64,727.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5,681.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,780.00
|
|
