|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 6068722411
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 6586262460
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 6909782103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 6909782103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 6068722401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN [219685]
|
Facility
|
OP
|
$12,979.92
|
|
|
Service Code
|
HCPCS J9203
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$224.32 |
| Max. Negotiated Rate |
$9,734.94 |
| Rate for Payer: Adventist Health Commercial |
$2,595.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,021.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$371.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$272.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$247.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$441.67
|
| Rate for Payer: Blue Shield of California Commercial |
$224.32
|
| Rate for Payer: Blue Shield of California EPN |
$224.32
|
| Rate for Payer: Cash Price |
$5,840.96
|
| Rate for Payer: Cash Price |
$5,840.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,970.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$309.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$272.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$272.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,307.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$247.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,009.70
|
| Rate for Payer: Heritage Provider Network Senior |
$6,009.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$247.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6,191.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,349.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$284.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,244.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$331.48
|
| Rate for Payer: Multiplan Commercial |
$9,734.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,191.97
|
| Rate for Payer: TriValley Medical Group Senior |
$5,191.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,689.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,297.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$309.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$272.11
|
| Rate for Payer: Vantage Medical Group Senior |
$272.11
|
|
|
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN [219685]
|
Facility
|
IP
|
$12,979.92
|
|
|
Service Code
|
HCPCS J9203
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,349.37 |
| Max. Negotiated Rate |
$9,734.94 |
| Rate for Payer: Adventist Health Commercial |
$2,595.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,359.07
|
| Rate for Payer: Cash Price |
$5,840.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,970.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,009.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,009.70
|
| Rate for Payer: Heritage Provider Network Senior |
$6,009.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,349.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,244.98
|
| Rate for Payer: Multiplan Commercial |
$9,734.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,689.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,297.65
|
|
|
GENTAMICIN 0.1 % TOPICAL CREAM [3423]
|
Facility
|
OP
|
$3.16
|
|
|
Service Code
|
NDC 4580205635
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1.93
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Senior |
$1.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.26
|
| Rate for Payer: TriValley Medical Group Senior |
$1.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.69
|
| Rate for Payer: Vantage Medical Group Senior |
$2.69
|
|
|
GENTAMICIN 0.1 % TOPICAL CREAM [3423]
|
Facility
|
IP
|
$3.16
|
|
|
Service Code
|
NDC 4580205635
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.04
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Senior |
$2.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
|
|
GENTAMICIN 0.1 % TOPICAL CREAM [3423]
|
Facility
|
OP
|
$3.16
|
|
|
Service Code
|
NDC 0713068315
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1.93
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Senior |
$1.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.26
|
| Rate for Payer: TriValley Medical Group Senior |
$1.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.69
|
| Rate for Payer: Vantage Medical Group Senior |
$2.69
|
|
|
GENTAMICIN 0.1 % TOPICAL CREAM [3423]
|
Facility
|
IP
|
$3.16
|
|
|
Service Code
|
NDC 0713068315
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.04
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Senior |
$2.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
|
|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
IP
|
$3.16
|
|
|
Service Code
|
NDC 4580204635
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.04
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Senior |
$2.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
|
|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
OP
|
$3.16
|
|
|
Service Code
|
NDC 4580204635
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1.93
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Senior |
$1.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.26
|
| Rate for Payer: TriValley Medical Group Senior |
$1.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.69
|
| Rate for Payer: Vantage Medical Group Senior |
$2.69
|
|
|
GENTAMICIN 0.3 % EYE DROPS [3428]
|
Facility
|
OP
|
$8.57
|
|
|
Service Code
|
NDC 2420858060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.29
|
| Rate for Payer: Blue Shield of California Commercial |
$5.23
|
| Rate for Payer: Blue Shield of California EPN |
$4.18
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.30
|
| Rate for Payer: Heritage Provider Network Senior |
$5.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$6.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.43
|
| Rate for Payer: TriValley Medical Group Senior |
$3.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.28
|
| Rate for Payer: Vantage Medical Group Senior |
$7.28
|
|
|
GENTAMICIN 0.3 % EYE DROPS [3428]
|
Facility
|
IP
|
$8.57
|
|
|
Service Code
|
NDC 2420858060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.52
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.80
|
| Rate for Payer: Heritage Provider Network Senior |
$5.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$6.43
|
|
|
GENTAMICIN 120 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [116094]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
|
|
GENTAMICIN 120 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [116094]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.96
|
| Rate for Payer: Blue Shield of California Commercial |
$3.10
|
| Rate for Payer: Blue Shield of California EPN |
$3.10
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]
|
Facility
|
OP
|
$2.17
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.96
|
| Rate for Payer: Blue Shield of California Commercial |
$3.10
|
| Rate for Payer: Blue Shield of California Commercial |
$3.10
|
| Rate for Payer: Blue Shield of California EPN |
$3.10
|
| Rate for Payer: Blue Shield of California EPN |
$3.10
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$1.71
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Senior |
$0.87
|
| Rate for Payer: TriValley Medical Group Senior |
$0.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.94
|
| Rate for Payer: Vantage Medical Group Senior |
$1.94
|
| Rate for Payer: Vantage Medical Group Senior |
$1.84
|
|
|
GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.47
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$1.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.72
|
|
|
GENTAMICIN 80 MG/50 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [15911]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.96
|
| Rate for Payer: Blue Shield of California Commercial |
$3.10
|
| Rate for Payer: Blue Shield of California EPN |
$3.10
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
GENTAMICIN 80 MG/50 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [15911]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
|
|
GENTAMICIN ORAL SOLUTION (IV FORM) 10 MG/ML [4080431]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
NDC 9994080431
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$1.46
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.49
|
| Rate for Payer: Heritage Provider Network Senior |
$1.49
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Senior |
$0.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
GENTAMICIN ORAL SOLUTION (IV FORM) 10 MG/ML [4080431]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
NDC 9994080431
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.55
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
|
|
GENTAMICIN (PF) 20 MG/2 ML MED NEB [4080723]
|
Facility
|
OP
|
$4.22
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.96
|
| Rate for Payer: Blue Shield of California Commercial |
$3.10
|
| Rate for Payer: Blue Shield of California EPN |
$3.10
|
| Rate for Payer: Cash Price |
$1.90
|
| Rate for Payer: Cash Price |
$1.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.59
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Senior |
$1.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.95
|
| Rate for Payer: Multiplan Commercial |
$3.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.69
|
| Rate for Payer: TriValley Medical Group Senior |
$1.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.59
|
| Rate for Payer: Vantage Medical Group Senior |
$3.59
|
|
|
GENTAMICIN (PF) 20 MG/2 ML MED NEB [4080723]
|
Facility
|
IP
|
$4.22
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.72
|
| Rate for Payer: Cash Price |
$1.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Senior |
$1.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.40
|
|
