|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D164KB
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D1687L
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D1607L
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D164K9
|
| Min. Negotiated Rate |
$10,600.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,600.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11,586.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D168KB
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D164JL
|
| Min. Negotiated Rate |
$10,600.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,600.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0DQ67ZZ
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D160KB
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0DT74ZZ
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D164KL
|
| Min. Negotiated Rate |
$10,600.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,600.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0DB63ZZ
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D160KL
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D160ZB
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D168K9
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0DB60ZZ
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D168JB
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D1647L
|
| Min. Negotiated Rate |
$10,600.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,600.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D1607A
|
| Min. Negotiated Rate |
$11,586.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11,586.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D1607B
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D1687A
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
BARICITINIB 1 MG TABLET [225594]
|
Facility
OP
|
$104.88
|
|
|
Service Code
|
NDC 0002-4732-30
|
| Hospital Charge Code |
ERX225594
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$89.15 |
| Rate for Payer: Adventist Health Commercial |
$20.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$56.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$89.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$57.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$78.66
|
| Rate for Payer: Blue Shield of California Commercial |
$65.13
|
| Rate for Payer: Blue Shield of California EPN |
$61.56
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$68.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.15
|
| Rate for Payer: Dignity Health Senior |
$89.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.92
|
| Rate for Payer: Heritage Provider Network Senior |
$64.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$50.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.22
|
| Rate for Payer: Multiplan Commercial |
$78.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.15
|
| Rate for Payer: Vantage Medical Group Senior |
$89.15
|
|
|
BARICITINIB 1 MG TABLET [225594]
|
Facility
IP
|
$104.88
|
|
|
Service Code
|
NDC 0002-4732-30
|
| Hospital Charge Code |
ERX225594
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$78.66 |
| Rate for Payer: Adventist Health Commercial |
$20.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.05
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.00
|
| Rate for Payer: Heritage Provider Network Senior |
$71.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.22
|
| Rate for Payer: Multiplan Commercial |
$78.66
|
|
|
BARICITINIB 2 MG TABLET [221907]
|
Facility
IP
|
$104.88
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
ERX221907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$78.66 |
| Rate for Payer: Adventist Health Commercial |
$20.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.05
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.00
|
| Rate for Payer: Heritage Provider Network Senior |
$71.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.22
|
| Rate for Payer: Multiplan Commercial |
$78.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$38.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$35.04
|
|
|
BARICITINIB 2 MG TABLET [221907]
|
Facility
OP
|
$104.88
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
ERX221907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$89.15 |
| Rate for Payer: Adventist Health Commercial |
$20.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$56.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$89.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$57.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$78.66
|
| Rate for Payer: Blue Shield of California Commercial |
$65.13
|
| Rate for Payer: Blue Shield of California EPN |
$61.56
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.15
|
| Rate for Payer: Dignity Health Senior |
$89.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.56
|
| Rate for Payer: Heritage Provider Network Senior |
$48.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$50.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.22
|
| Rate for Payer: Multiplan Commercial |
$78.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$38.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$35.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.15
|
| Rate for Payer: Vantage Medical Group Senior |
$89.15
|
|
|
BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 32909-167-55
|
| Hospital Charge Code |
NDG972961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
