|
BEBTELOVIMAB 175 MG/2 ML (87.5 MG/ML) INTRAVENOUS SOLUTION (UNAPP) [233528]
|
Facility
OP
|
$1,260.00
|
|
|
Service Code
|
CPT Q0222
|
| Hospital Charge Code |
NDG233528
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$228.06 |
| Max. Negotiated Rate |
$5,964.76 |
| Rate for Payer: Adventist Health Commercial |
$252.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5,822.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$865.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,924.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,453.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,453.28
|
| Rate for Payer: Blue Shield of California Commercial |
$2,142.00
|
| Rate for Payer: Blue Shield of California EPN |
$2,142.00
|
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$579.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,709.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,453.28
|
| Rate for Payer: Dignity Health Senior |
$3,453.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$806.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,139.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$583.38
|
| Rate for Payer: Heritage Provider Network Senior |
$583.38
|
| Rate for Payer: Humana Medicare |
$3,139.35
|
| Rate for Payer: IEHP Medicare Advantage |
$3,139.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,964.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$228.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,704.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$315.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,955.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,955.58
|
| Rate for Payer: Multiplan Commercial |
$945.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,453.28
|
| Rate for Payer: TriValley Medical Group Senior |
$3,139.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$459.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$420.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,709.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,453.28
|
| Rate for Payer: Vantage Medical Group Senior |
$3,139.35
|
|
|
BEBTELOVIMAB 175 MG/2 ML (87.5 MG/ML) INTRAVENOUS SOLUTION (UNAPP) [233528]
|
Facility
IP
|
$1,260.00
|
|
|
Service Code
|
CPT Q0222
|
| Hospital Charge Code |
NDG233528
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$228.06 |
| Max. Negotiated Rate |
$945.00 |
| Rate for Payer: Adventist Health Commercial |
$252.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$865.62
|
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$579.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$680.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$853.02
|
| Rate for Payer: Heritage Provider Network Senior |
$853.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$228.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$315.00
|
| Rate for Payer: Multiplan Commercial |
$945.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$459.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$420.97
|
|
|
BECLOMETHASONE ORAL EMULSION COMPOUND 1 MG/ML [4080247]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 9994-0802-47
|
| Hospital Charge Code |
1715210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
BECLOMETHASONE ORAL EMULSION COMPOUND 1 MG/ML [4080247]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 9994-0802-47
|
| Hospital Charge Code |
1715210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
BEER [4080757]
|
Facility
OP
|
$1.43
|
|
|
Service Code
|
NDC 9994-0807-57
|
| Hospital Charge Code |
ERX4080757
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.89
|
| Rate for Payer: Blue Shield of California EPN |
$0.84
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.22
|
| Rate for Payer: Dignity Health Senior |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
BEER [4080757]
|
Facility
IP
|
$1.43
|
|
|
Service Code
|
NDC 9994-0807-57
|
| Hospital Charge Code |
ERX4080757
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
|
|
BEHAVIORAL DISORDERS
|
Facility
IP
|
$4,060.17
|
|
|
Service Code
|
APR-DRG 7582
|
| Min. Negotiated Rate |
$4,060.17 |
| Max. Negotiated Rate |
$4,060.17 |
| Rate for Payer: IEHP Medi-Cal |
$4,060.17
|
|
|
BEHAVIORAL DISORDERS
|
Facility
IP
|
$7,079.68
|
|
|
Service Code
|
APR-DRG 7583
|
| Min. Negotiated Rate |
$7,079.68 |
| Max. Negotiated Rate |
$7,079.68 |
| Rate for Payer: IEHP Medi-Cal |
$7,079.68
|
|
|
BEHAVIORAL DISORDERS
|
Facility
IP
|
$3,282.16
|
|
|
Service Code
|
APR-DRG 7581
|
| Min. Negotiated Rate |
$3,282.16 |
| Max. Negotiated Rate |
$3,282.16 |
| Rate for Payer: IEHP Medi-Cal |
$3,282.16
|
|
|
BEHAVIORAL DISORDERS
|
Facility
IP
|
$9,344.06
|
|
|
Service Code
|
APR-DRG 7584
|
| Min. Negotiated Rate |
$9,344.06 |
| Max. Negotiated Rate |
$9,344.06 |
| Rate for Payer: IEHP Medi-Cal |
$9,344.06
|
|
|
BELANTAMAB MAFODOTIN-BLMF 100 MG INTRAVENOUS SOLUTION [229004]
|
Facility
IP
|
$10,591.76
|
|
|
Service Code
|
CPT J9037
|
| Hospital Charge Code |
ERX229004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,917.11 |
| Max. Negotiated Rate |
$7,943.82 |
| Rate for Payer: Adventist Health Commercial |
$2,118.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,276.54
|
| Rate for Payer: Cash Price |
$4,766.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,872.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,719.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,170.62
|
| Rate for Payer: Heritage Provider Network Senior |
$7,170.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,917.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,647.94
|
| Rate for Payer: Multiplan Commercial |
$7,943.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,861.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,538.71
|
|
|
BELANTAMAB MAFODOTIN-BLMF 100 MG INTRAVENOUS SOLUTION [229004]
|
Facility
OP
|
$10,591.76
|
|
|
Service Code
|
CPT J9037
|
| Hospital Charge Code |
ERX229004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.02 |
| Max. Negotiated Rate |
$7,943.82 |
| Rate for Payer: Adventist Health Commercial |
$2,118.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$85.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,276.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$58.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$51.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$51.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$88.43
|
| Rate for Payer: Blue Shield of California Commercial |
$45.02
|
| Rate for Payer: Blue Shield of California EPN |
$45.02
|
| Rate for Payer: Cash Price |
$4,766.29
|
| Rate for Payer: Cash Price |
$4,766.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,872.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$58.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.46
|
| Rate for Payer: Dignity Health Senior |
$51.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,778.73
|
| Rate for Payer: EPIC Health Plan Medicare |
$46.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,903.98
|
| Rate for Payer: Heritage Provider Network Senior |
$4,903.98
|
| Rate for Payer: Humana Medicare |
$46.78
|
| Rate for Payer: IEHP Medi-Cal |
$77.59
|
| Rate for Payer: IEHP Medicare Advantage |
$46.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$88.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,917.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$55.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,647.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$58.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$58.94
|
| Rate for Payer: Multiplan Commercial |
$7,943.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$51.46
|
| Rate for Payer: TriValley Medical Group Senior |
$46.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,861.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,538.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$58.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.46
|
| Rate for Payer: Vantage Medical Group Senior |
$51.46
|
|
|
BELATACEPT 250 MG INTRAVENOUS SOLUTION [153042]
|
Facility
OP
|
$1,163.86
|
|
|
Service Code
|
CPT J0485
|
| Hospital Charge Code |
ERX153042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.86 |
| Max. Negotiated Rate |
$872.90 |
| Rate for Payer: Adventist Health Commercial |
$232.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$799.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.90
|
| Rate for Payer: Blue Shield of California Commercial |
$3.86
|
| Rate for Payer: Blue Shield of California EPN |
$3.86
|
| Rate for Payer: Cash Price |
$523.74
|
| Rate for Payer: Cash Price |
$523.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$535.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.26
|
| Rate for Payer: Dignity Health Senior |
$4.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$744.87
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$538.87
|
| Rate for Payer: Heritage Provider Network Senior |
$538.87
|
| Rate for Payer: Humana Medicare |
$3.87
|
| Rate for Payer: IEHP Medi-Cal |
$12.99
|
| Rate for Payer: IEHP Medicare Advantage |
$3.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$210.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$290.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.88
|
| Rate for Payer: Multiplan Commercial |
$872.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.26
|
| Rate for Payer: TriValley Medical Group Senior |
$3.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$424.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$388.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.26
|
| Rate for Payer: Vantage Medical Group Senior |
$3.87
|
|
|
BELATACEPT 250 MG INTRAVENOUS SOLUTION [153042]
|
Facility
IP
|
$1,163.86
|
|
|
Service Code
|
CPT J0485
|
| Hospital Charge Code |
ERX153042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.66 |
| Max. Negotiated Rate |
$872.90 |
| Rate for Payer: Adventist Health Commercial |
$232.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$799.57
|
| Rate for Payer: Cash Price |
$523.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$535.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$628.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$787.93
|
| Rate for Payer: Heritage Provider Network Senior |
$787.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$210.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$290.96
|
| Rate for Payer: Multiplan Commercial |
$872.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$424.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$388.85
|
|
|
BELIMUMAB 120 MG INTRAVENOUS SOLUTION [108842]
|
Facility
OP
|
$707.42
|
|
|
Service Code
|
CPT J0490
|
| Hospital Charge Code |
1755787
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.37 |
| Max. Negotiated Rate |
$530.56 |
| Rate for Payer: Adventist Health Commercial |
$141.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$127.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$486.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$65.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$57.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$57.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$78.95
|
| Rate for Payer: Blue Shield of California Commercial |
$49.37
|
| Rate for Payer: Blue Shield of California EPN |
$49.37
|
| Rate for Payer: Cash Price |
$318.34
|
| Rate for Payer: Cash Price |
$318.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$325.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$78.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$57.20
|
| Rate for Payer: Dignity Health Senior |
$57.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$452.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$52.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$327.54
|
| Rate for Payer: Heritage Provider Network Senior |
$327.54
|
| Rate for Payer: Humana Medicare |
$52.00
|
| Rate for Payer: IEHP Medi-Cal |
$88.08
|
| Rate for Payer: IEHP Medicare Advantage |
$52.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$98.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$61.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$176.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$65.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$65.52
|
| Rate for Payer: Multiplan Commercial |
$530.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$57.20
|
| Rate for Payer: TriValley Medical Group Senior |
$52.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$257.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$236.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$78.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.20
|
| Rate for Payer: Vantage Medical Group Senior |
$52.00
|
|
|
BELIMUMAB 120 MG INTRAVENOUS SOLUTION [108842]
|
Facility
IP
|
$707.42
|
|
|
Service Code
|
CPT J0490
|
| Hospital Charge Code |
1755787
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$128.04 |
| Max. Negotiated Rate |
$530.56 |
| Rate for Payer: Adventist Health Commercial |
$141.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$486.00
|
| Rate for Payer: Cash Price |
$318.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$325.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$382.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$478.92
|
| Rate for Payer: Heritage Provider Network Senior |
$478.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$176.86
|
| Rate for Payer: Multiplan Commercial |
$530.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$257.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$236.35
|
|
|
BELIMUMAB 400 MG INTRAVENOUS SOLUTION [108843]
|
Facility
OP
|
$2,357.96
|
|
|
Service Code
|
CPT J0490
|
| Hospital Charge Code |
1755788
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.37 |
| Max. Negotiated Rate |
$1,768.47 |
| Rate for Payer: Adventist Health Commercial |
$471.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$127.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,619.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$65.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$57.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$57.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$78.95
|
| Rate for Payer: Blue Shield of California Commercial |
$49.37
|
| Rate for Payer: Blue Shield of California EPN |
$49.37
|
| Rate for Payer: Cash Price |
$1,061.08
|
| Rate for Payer: Cash Price |
$1,061.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,084.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$78.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$57.20
|
| Rate for Payer: Dignity Health Senior |
$57.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,509.09
|
| Rate for Payer: EPIC Health Plan Medicare |
$52.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,091.74
|
| Rate for Payer: Heritage Provider Network Senior |
$1,091.74
|
| Rate for Payer: Humana Medicare |
$52.00
|
| Rate for Payer: IEHP Medi-Cal |
$88.08
|
| Rate for Payer: IEHP Medicare Advantage |
$52.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$98.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$426.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$61.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$589.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$65.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$65.52
|
| Rate for Payer: Multiplan Commercial |
$1,768.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$57.20
|
| Rate for Payer: TriValley Medical Group Senior |
$52.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$859.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$787.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$78.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.20
|
| Rate for Payer: Vantage Medical Group Senior |
$52.00
|
|
|
BELIMUMAB 400 MG INTRAVENOUS SOLUTION [108843]
|
Facility
IP
|
$2,357.96
|
|
|
Service Code
|
CPT J0490
|
| Hospital Charge Code |
1755788
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$426.79 |
| Max. Negotiated Rate |
$1,768.47 |
| Rate for Payer: Adventist Health Commercial |
$471.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,619.92
|
| Rate for Payer: Cash Price |
$1,061.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,084.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,273.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,596.34
|
| Rate for Payer: Heritage Provider Network Senior |
$1,596.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$426.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$589.49
|
| Rate for Payer: Multiplan Commercial |
$1,768.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$859.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$787.79
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
OP
|
$26.42
|
|
|
Service Code
|
NDC 0574-7045-12
|
| Hospital Charge Code |
ERX111311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$22.46 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$22.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.82
|
| Rate for Payer: Blue Shield of California Commercial |
$16.41
|
| Rate for Payer: Blue Shield of California EPN |
$15.51
|
| Rate for Payer: Cash Price |
$11.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.46
|
| Rate for Payer: Dignity Health Senior |
$22.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.35
|
| Rate for Payer: Heritage Provider Network Senior |
$16.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.46
|
| Rate for Payer: Vantage Medical Group Senior |
$22.46
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
IP
|
$26.42
|
|
|
Service Code
|
NDC 0574-7045-01
|
| Hospital Charge Code |
ERX111311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$19.82 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.15
|
| Rate for Payer: Cash Price |
$11.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.89
|
| Rate for Payer: Heritage Provider Network Senior |
$17.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
IP
|
$26.42
|
|
|
Service Code
|
NDC 0574-7045-12
|
| Hospital Charge Code |
ERX111311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$19.82 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.15
|
| Rate for Payer: Cash Price |
$11.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.89
|
| Rate for Payer: Heritage Provider Network Senior |
$17.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
OP
|
$26.42
|
|
|
Service Code
|
NDC 0574-7045-01
|
| Hospital Charge Code |
ERX111311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$22.46 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$22.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.82
|
| Rate for Payer: Blue Shield of California Commercial |
$16.41
|
| Rate for Payer: Blue Shield of California EPN |
$15.51
|
| Rate for Payer: Cash Price |
$11.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.46
|
| Rate for Payer: Dignity Health Senior |
$22.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.35
|
| Rate for Payer: Heritage Provider Network Senior |
$16.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.46
|
| Rate for Payer: Vantage Medical Group Senior |
$22.46
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
IP
|
$32.11
|
|
|
Service Code
|
NDC 0574-7040-01
|
| Hospital Charge Code |
1736001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.81 |
| Max. Negotiated Rate |
$24.08 |
| Rate for Payer: Adventist Health Commercial |
$6.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.06
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.74
|
| Rate for Payer: Heritage Provider Network Senior |
$21.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.03
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
OP
|
$32.11
|
|
|
Service Code
|
NDC 0574-7040-01
|
| Hospital Charge Code |
1736001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.81 |
| Max. Negotiated Rate |
$27.29 |
| Rate for Payer: Adventist Health Commercial |
$6.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$24.08
|
| Rate for Payer: Blue Shield of California Commercial |
$19.94
|
| Rate for Payer: Blue Shield of California EPN |
$18.85
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.29
|
| Rate for Payer: Dignity Health Senior |
$27.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.88
|
| Rate for Payer: Heritage Provider Network Senior |
$19.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.03
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.29
|
| Rate for Payer: Vantage Medical Group Senior |
$27.29
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
IP
|
$32.11
|
|
|
Service Code
|
NDC 0574-7040-12
|
| Hospital Charge Code |
1736001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.81 |
| Max. Negotiated Rate |
$24.08 |
| Rate for Payer: Adventist Health Commercial |
$6.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.06
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.74
|
| Rate for Payer: Heritage Provider Network Senior |
$21.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.03
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
|
