|
AUTOLOGOUS BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$42,377.59
|
|
|
Service Code
|
APR-DRG 0083
|
| Min. Negotiated Rate |
$42,377.59 |
| Max. Negotiated Rate |
$42,377.59 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$42,377.59
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$67,299.74
|
|
|
Service Code
|
APR-DRG 0084
|
| Min. Negotiated Rate |
$67,299.74 |
| Max. Negotiated Rate |
$67,299.74 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$67,299.74
|
|
|
Autologous chondrocyte implantation, knee
|
Facility
|
OP
|
$16,983.21
|
|
|
Service Code
|
CPT 27412
|
| Min. Negotiated Rate |
$1,301.79 |
| Max. Negotiated Rate |
$16,983.21 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,938.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,832.38
|
| Rate for Payer: Dignity Health Senior |
$8,938.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$8,938.53
|
| Rate for Payer: Humana Medicare |
$8,938.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,301.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,938.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16,983.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10,547.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,262.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11,262.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,832.38
|
| Rate for Payer: TriValley Medical Group Senior |
$8,938.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Vantage Medical Group Senior |
$8,938.53
|
|
|
AVAPRITINIB 100 MG TABLET [226931]
|
Facility
|
OP
|
$1,408.52
|
|
|
Service Code
|
NDC 72064-110-30
|
| Hospital Charge Code |
ERX226931
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$254.94 |
| Max. Negotiated Rate |
$1,197.24 |
| Rate for Payer: Adventist Health Commercial |
$281.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$752.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$967.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,197.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$774.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,056.39
|
| Rate for Payer: Blue Shield of California Commercial |
$874.69
|
| Rate for Payer: Blue Shield of California EPN |
$826.80
|
| Rate for Payer: Cash Price |
$633.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$915.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,197.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,197.24
|
| Rate for Payer: Dignity Health Senior |
$1,197.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$901.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$871.87
|
| Rate for Payer: Heritage Provider Network Senior |
$871.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$678.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$254.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$352.13
|
| Rate for Payer: Multiplan Commercial |
$1,056.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$563.41
|
| Rate for Payer: TriValley Medical Group Senior |
$563.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,197.24
|
| Rate for Payer: Vantage Medical Group Senior |
$1,197.24
|
|
|
AVAPRITINIB 100 MG TABLET [226931]
|
Facility
|
IP
|
$1,408.52
|
|
|
Service Code
|
NDC 72064-110-30
|
| Hospital Charge Code |
ERX226931
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$254.94 |
| Max. Negotiated Rate |
$1,056.39 |
| Rate for Payer: Adventist Health Commercial |
$281.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$967.65
|
| Rate for Payer: Cash Price |
$633.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$760.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$953.57
|
| Rate for Payer: Heritage Provider Network Senior |
$953.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$254.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$352.13
|
| Rate for Payer: Multiplan Commercial |
$1,056.39
|
|
|
AVAPRITINIB 200 MG TABLET [226932]
|
Facility
|
IP
|
$1,408.52
|
|
|
Service Code
|
NDC 72064-120-30
|
| Hospital Charge Code |
ERX226932
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$254.94 |
| Max. Negotiated Rate |
$1,056.39 |
| Rate for Payer: Adventist Health Commercial |
$281.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$967.65
|
| Rate for Payer: Cash Price |
$633.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$760.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$953.57
|
| Rate for Payer: Heritage Provider Network Senior |
$953.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$254.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$352.13
|
| Rate for Payer: Multiplan Commercial |
$1,056.39
|
|
|
AVAPRITINIB 200 MG TABLET [226932]
|
Facility
|
OP
|
$1,408.52
|
|
|
Service Code
|
NDC 72064-120-30
|
| Hospital Charge Code |
ERX226932
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$254.94 |
| Max. Negotiated Rate |
$1,197.24 |
| Rate for Payer: Adventist Health Commercial |
$281.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$752.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$967.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,197.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$774.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,056.39
|
| Rate for Payer: Blue Shield of California Commercial |
$874.69
|
| Rate for Payer: Blue Shield of California EPN |
$826.80
|
| Rate for Payer: Cash Price |
$633.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$915.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,197.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,197.24
|
| Rate for Payer: Dignity Health Senior |
$1,197.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$901.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$871.87
|
| Rate for Payer: Heritage Provider Network Senior |
$871.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$678.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$254.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$352.13
|
| Rate for Payer: Multiplan Commercial |
$1,056.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$563.41
|
| Rate for Payer: TriValley Medical Group Senior |
$563.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,197.24
|
| Rate for Payer: Vantage Medical Group Senior |
$1,197.24
|
|
|
AVAPRITINIB 300 MG TABLET [226933]
|
Facility
|
OP
|
$1,408.52
|
|
|
Service Code
|
NDC 72064-130-30
|
| Hospital Charge Code |
ERX226933
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$254.94 |
| Max. Negotiated Rate |
$1,197.24 |
| Rate for Payer: Adventist Health Commercial |
$281.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$752.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$967.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,197.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$774.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,056.39
|
| Rate for Payer: Blue Shield of California Commercial |
$874.69
|
| Rate for Payer: Blue Shield of California EPN |
$826.80
|
| Rate for Payer: Cash Price |
$633.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$915.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,197.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,197.24
|
| Rate for Payer: Dignity Health Senior |
$1,197.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$901.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$871.87
|
| Rate for Payer: Heritage Provider Network Senior |
$871.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$678.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$254.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$352.13
|
| Rate for Payer: Multiplan Commercial |
$1,056.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$563.41
|
| Rate for Payer: TriValley Medical Group Senior |
$563.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,197.24
|
| Rate for Payer: Vantage Medical Group Senior |
$1,197.24
|
|
|
AVAPRITINIB 300 MG TABLET [226933]
|
Facility
|
IP
|
$1,408.52
|
|
|
Service Code
|
NDC 72064-130-30
|
| Hospital Charge Code |
ERX226933
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$254.94 |
| Max. Negotiated Rate |
$1,056.39 |
| Rate for Payer: Adventist Health Commercial |
$281.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$967.65
|
| Rate for Payer: Cash Price |
$633.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$760.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$953.57
|
| Rate for Payer: Heritage Provider Network Senior |
$953.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$254.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$352.13
|
| Rate for Payer: Multiplan Commercial |
$1,056.39
|
|
|
AZACITIDINE 100 MG (10 MG/ML) INTRAVENOUS INJECTION [40878420]
|
Facility
|
IP
|
$702.29
|
|
|
Service Code
|
CPT J9025
|
| Hospital Charge Code |
ERX40878420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.11 |
| Max. Negotiated Rate |
$526.72 |
| Rate for Payer: Adventist Health Commercial |
$140.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$482.47
|
| Rate for Payer: Cash Price |
$316.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$323.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$379.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$475.45
|
| Rate for Payer: Heritage Provider Network Senior |
$475.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$175.57
|
| Rate for Payer: Multiplan Commercial |
$526.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$256.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$234.64
|
|
|
AZACITIDINE 100 MG (10 MG/ML) INTRAVENOUS INJECTION [40878420]
|
Facility
|
OP
|
$702.29
|
|
|
Service Code
|
CPT J9025
|
| Hospital Charge Code |
ERX40878420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$596.95 |
| Rate for Payer: Adventist Health Commercial |
$140.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$482.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$596.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$386.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$526.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.03
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Cash Price |
$316.03
|
| Rate for Payer: Cash Price |
$316.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$323.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$596.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$596.95
|
| Rate for Payer: Dignity Health Senior |
$596.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$449.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$325.16
|
| Rate for Payer: Heritage Provider Network Senior |
$325.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$338.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$175.57
|
| Rate for Payer: Multiplan Commercial |
$526.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$280.92
|
| Rate for Payer: TriValley Medical Group Senior |
$280.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$256.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$234.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$596.95
|
| Rate for Payer: Vantage Medical Group Senior |
$596.95
|
|
|
AZACITIDINE 100 MG (25 MG/ML) SUBCUTANEOUS INJECTION [408000276]
|
Facility
|
IP
|
$210.00
|
|
|
Service Code
|
CPT J9025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.01 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Adventist Health Commercial |
$43.20
|
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$144.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$148.39
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$49.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$99.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$116.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$146.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$142.17
|
| Rate for Payer: Heritage Provider Network Senior |
$142.17
|
| Rate for Payer: Heritage Provider Network Senior |
$73.12
|
| Rate for Payer: Heritage Provider Network Senior |
$81.24
|
| Rate for Payer: Heritage Provider Network Senior |
$146.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$81.00
|
| Rate for Payer: Multiplan Commercial |
$157.50
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$162.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$76.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$78.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$70.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$72.17
|
|
|
AZACITIDINE 100 MG (25 MG/ML) SUBCUTANEOUS INJECTION [408000276]
|
Facility
|
OP
|
$216.00
|
|
|
Service Code
|
CPT J9025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$183.60 |
| Rate for Payer: Adventist Health Commercial |
$43.20
|
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$144.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$148.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$178.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$183.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$91.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$118.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$59.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$115.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$157.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$90.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$81.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$162.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.03
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$49.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$99.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$178.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$91.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$183.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$183.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$91.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$178.50
|
| Rate for Payer: Dignity Health Senior |
$178.50
|
| Rate for Payer: Dignity Health Senior |
$183.60
|
| Rate for Payer: Dignity Health Senior |
$91.80
|
| Rate for Payer: Dignity Health Senior |
$102.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$138.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$134.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$100.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$97.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.00
|
| Rate for Payer: Heritage Provider Network Senior |
$97.23
|
| Rate for Payer: Heritage Provider Network Senior |
$55.56
|
| Rate for Payer: Heritage Provider Network Senior |
$50.00
|
| Rate for Payer: Heritage Provider Network Senior |
$100.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$52.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$101.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$104.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$57.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$81.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$162.00
|
| Rate for Payer: Multiplan Commercial |
$157.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$86.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$84.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$48.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.20
|
| Rate for Payer: TriValley Medical Group Senior |
$43.20
|
| Rate for Payer: TriValley Medical Group Senior |
$84.00
|
| Rate for Payer: TriValley Medical Group Senior |
$48.00
|
| Rate for Payer: TriValley Medical Group Senior |
$86.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$78.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$76.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$70.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$72.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$178.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$91.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$183.60
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
| Rate for Payer: Vantage Medical Group Senior |
$91.80
|
| Rate for Payer: Vantage Medical Group Senior |
$183.60
|
| Rate for Payer: Vantage Medical Group Senior |
$178.50
|
|
|
AZACITIDINE 100 MG INJECTION [78420]
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT J9025
|
| Hospital Charge Code |
1755716
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.72 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$144.27
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$142.17
|
| Rate for Payer: Heritage Provider Network Senior |
$142.17
|
| Rate for Payer: Heritage Provider Network Senior |
$81.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$157.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$76.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$70.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.09
|
|
|
AZACITIDINE 100 MG INJECTION [78420]
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
CPT J9025
|
| Hospital Charge Code |
1755716
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$178.50 |
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$144.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$178.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$115.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$157.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$90.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.03
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$178.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$178.50
|
| Rate for Payer: Dignity Health Senior |
$178.50
|
| Rate for Payer: Dignity Health Senior |
$102.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$134.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$97.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.56
|
| Rate for Payer: Heritage Provider Network Senior |
$55.56
|
| Rate for Payer: Heritage Provider Network Senior |
$97.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$101.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$57.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: Multiplan Commercial |
$157.50
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$48.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$84.00
|
| Rate for Payer: TriValley Medical Group Senior |
$48.00
|
| Rate for Payer: TriValley Medical Group Senior |
$84.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$76.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$70.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$178.50
|
| Rate for Payer: Vantage Medical Group Senior |
$178.50
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
|
|
AZATHIOPRINE 25 MG 1/2 TAB [4081407]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
CPT J7500
|
| Hospital Charge Code |
ERX4081407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$215.25 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$215.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$215.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$215.25
|
| Rate for Payer: Blue Shield of California Commercial |
$3.20
|
| Rate for Payer: Blue Shield of California Commercial |
$3.20
|
| Rate for Payer: Blue Shield of California Commercial |
$3.20
|
| Rate for Payer: Blue Shield of California EPN |
$3.20
|
| Rate for Payer: Blue Shield of California EPN |
$3.20
|
| Rate for Payer: Blue Shield of California EPN |
$3.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.56
|
| Rate for Payer: Dignity Health Senior |
$0.35
|
| Rate for Payer: Dignity Health Senior |
$0.56
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.56
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
|
|
AZATHIOPRINE 25 MG 1/2 TAB [4081407]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
CPT J7500
|
| Hospital Charge Code |
NDC4081407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
|
|
AZATHIOPRINE 25 MG 1/2 TAB [4081407]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
CPT J7500
|
| Hospital Charge Code |
NDC4081407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$215.25 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$215.25
|
| Rate for Payer: Blue Shield of California Commercial |
$3.20
|
| Rate for Payer: Blue Shield of California EPN |
$3.20
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
|
|
AZATHIOPRINE 25 MG 1/2 TAB [4081407]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
CPT J7500
|
| Hospital Charge Code |
ERX4081407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
|
|
AZATHIOPRINE 50 MG TABLET [9183]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
CPT J7500
|
| Hospital Charge Code |
1710262
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$215.25 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$215.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$215.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$215.25
|
| Rate for Payer: Blue Shield of California Commercial |
$3.20
|
| Rate for Payer: Blue Shield of California Commercial |
$3.20
|
| Rate for Payer: Blue Shield of California Commercial |
$3.20
|
| Rate for Payer: Blue Shield of California EPN |
$3.20
|
| Rate for Payer: Blue Shield of California EPN |
$3.20
|
| Rate for Payer: Blue Shield of California EPN |
$3.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.56
|
| Rate for Payer: Dignity Health Senior |
$0.35
|
| Rate for Payer: Dignity Health Senior |
$0.56
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.56
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
|
|
AZATHIOPRINE 50 MG TABLET [9183]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
CPT J7500
|
| Hospital Charge Code |
1710262
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
|
|
AZATHIOPRINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080245]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
CPT J7500
|
| Hospital Charge Code |
NDG4080245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$215.25 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$215.25
|
| Rate for Payer: Blue Shield of California Commercial |
$3.20
|
| Rate for Payer: Blue Shield of California EPN |
$3.20
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
|
|
AZATHIOPRINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080245]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
CPT J7500
|
| Hospital Charge Code |
NDG4080245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
|
|
AZELASTINE 0.05 % EYE DROPS [28351]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 61314-308-02
|
| Hospital Charge Code |
1740346
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.95 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.25
|
| Rate for Payer: Blue Shield of California Commercial |
$4.35
|
| Rate for Payer: Blue Shield of California EPN |
$4.11
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.95
|
| Rate for Payer: Dignity Health Senior |
$5.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.33
|
| Rate for Payer: Heritage Provider Network Senior |
$4.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$5.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.80
|
| Rate for Payer: TriValley Medical Group Senior |
$2.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.95
|
| Rate for Payer: Vantage Medical Group Senior |
$5.95
|
|
|
AZELASTINE 0.05 % EYE DROPS [28351]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 61314-308-02
|
| Hospital Charge Code |
1740346
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.25 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.81
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.74
|
| Rate for Payer: Heritage Provider Network Senior |
$4.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$5.25
|
|
