|
BETHANECHOL CHLORIDE 25 MG TABLET [1044]
|
Facility
IP
|
$1.10
|
|
|
Service Code
|
NDC 0832-0512-01
|
| Hospital Charge Code |
1711230
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.76
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
|
|
BETHANECHOL CHLORIDE 25 MG TABLET [1044]
|
Facility
IP
|
$1.09
|
|
|
Service Code
|
NDC 0832-0512-89
|
| Hospital Charge Code |
1711230
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
|
|
BETHANECHOL CHLORIDE 25 MG TABLET [1044]
|
Facility
IP
|
$0.61
|
|
|
Service Code
|
NDC 0527-1356-01
|
| Hospital Charge Code |
1711230
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
BETHANECHOL CHLORIDE 25 MG TABLET [1044]
|
Facility
OP
|
$0.55
|
|
|
Service Code
|
NDC 65162-573-10
|
| Hospital Charge Code |
1711230
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: Dignity Health Senior |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
|
BETHANECHOL CHLORIDE 25 MG TABLET [1044]
|
Facility
OP
|
$0.61
|
|
|
Service Code
|
NDC 0527-1356-01
|
| Hospital Charge Code |
1711230
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.52
|
| Rate for Payer: Dignity Health Senior |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| 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 |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
|
|
BETHANECHOL CHLORIDE 25 MG TABLET [1044]
|
Facility
IP
|
$0.55
|
|
|
Service Code
|
NDC 0832-0512-00
|
| Hospital Charge Code |
1711230
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
BETHANECHOL CHLORIDE 25 MG TABLET [1044]
|
Facility
OP
|
$1.09
|
|
|
Service Code
|
NDC 0832-0512-89
|
| Hospital Charge Code |
1711230
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.93
|
| Rate for Payer: Dignity Health Senior |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.93
|
| Rate for Payer: Vantage Medical Group Senior |
$0.93
|
|
|
BETHANECHOL CHLORIDE 25 MG TABLET [1044]
|
Facility
OP
|
$0.55
|
|
|
Service Code
|
NDC 0832-0512-00
|
| Hospital Charge Code |
1711230
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: Dignity Health Senior |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
|
BETHANECHOL CHLORIDE 5 MG TABLET [1045]
|
Facility
IP
|
$0.29
|
|
|
Service Code
|
NDC 0832-0510-00
|
| Hospital Charge Code |
1711212
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
BETHANECHOL CHLORIDE 5 MG TABLET [1045]
|
Facility
OP
|
$0.29
|
|
|
Service Code
|
NDC 0832-0510-00
|
| Hospital Charge Code |
1711212
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Senior |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
BETHANECHOL ORAL SUSPENSION COMPOUND 1 MG/ML [4080248]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 9994-0802-48
|
| Hospital Charge Code |
1715519
|
|
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
|
|
|
BETHANECHOL ORAL SUSPENSION COMPOUND 1 MG/ML [4080248]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 9994-0802-48
|
| Hospital Charge Code |
1715519
|
|
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
|
|
|
BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [38022]
|
Facility
OP
|
$239.08
|
|
|
Service Code
|
CPT J9035
|
| Hospital Charge Code |
1722042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.27 |
| Max. Negotiated Rate |
$179.31 |
| Rate for Payer: Adventist Health Commercial |
$47.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$145.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$92.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$81.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$81.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$122.45
|
| Rate for Payer: Blue Shield of California Commercial |
$81.29
|
| Rate for Payer: Blue Shield of California EPN |
$81.29
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$111.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.48
|
| Rate for Payer: Dignity Health Senior |
$81.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$153.01
|
| Rate for Payer: EPIC Health Plan Medicare |
$74.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.69
|
| Rate for Payer: Heritage Provider Network Senior |
$110.69
|
| Rate for Payer: Humana Medicare |
$74.07
|
| Rate for Payer: IEHP Medi-Cal |
$122.51
|
| Rate for Payer: IEHP Medicare Advantage |
$74.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$140.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$87.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$93.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$93.33
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$81.48
|
| Rate for Payer: TriValley Medical Group Senior |
$74.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$79.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$111.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.48
|
| Rate for Payer: Vantage Medical Group Senior |
$74.07
|
|
|
BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [38022]
|
Facility
IP
|
$239.08
|
|
|
Service Code
|
CPT J9035
|
| Hospital Charge Code |
1722041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.27 |
| Max. Negotiated Rate |
$179.31 |
| Rate for Payer: Adventist Health Commercial |
$47.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.25
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$129.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$161.86
|
| Rate for Payer: Heritage Provider Network Senior |
$161.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.77
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$79.88
|
|
|
BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [38022]
|
Facility
IP
|
$239.08
|
|
|
Service Code
|
CPT J9035
|
| Hospital Charge Code |
1722042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.27 |
| Max. Negotiated Rate |
$179.31 |
| Rate for Payer: Adventist Health Commercial |
$47.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.25
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$129.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$161.86
|
| Rate for Payer: Heritage Provider Network Senior |
$161.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.77
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$79.88
|
|
|
BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [38022]
|
Facility
OP
|
$239.08
|
|
|
Service Code
|
CPT J9035
|
| Hospital Charge Code |
1722041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.27 |
| Max. Negotiated Rate |
$179.31 |
| Rate for Payer: Adventist Health Commercial |
$47.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$145.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$92.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$81.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$81.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$122.45
|
| Rate for Payer: Blue Shield of California Commercial |
$81.29
|
| Rate for Payer: Blue Shield of California EPN |
$81.29
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$111.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.48
|
| Rate for Payer: Dignity Health Senior |
$81.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$153.01
|
| Rate for Payer: EPIC Health Plan Medicare |
$74.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.69
|
| Rate for Payer: Heritage Provider Network Senior |
$110.69
|
| Rate for Payer: Humana Medicare |
$74.07
|
| Rate for Payer: IEHP Medi-Cal |
$122.51
|
| Rate for Payer: IEHP Medicare Advantage |
$74.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$140.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$87.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$93.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$93.33
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$81.48
|
| Rate for Payer: TriValley Medical Group Senior |
$74.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$79.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$111.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.48
|
| Rate for Payer: Vantage Medical Group Senior |
$74.07
|
|
|
BEVACIZUMAB 25 MG/ML INTRAVITREAL INJ [4080972]
|
Facility
IP
|
$239.08
|
|
|
Service Code
|
CPT C9257
|
| Hospital Charge Code |
1722041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.27 |
| Max. Negotiated Rate |
$179.31 |
| Rate for Payer: Adventist Health Commercial |
$47.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.25
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$129.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$161.86
|
| Rate for Payer: Heritage Provider Network Senior |
$161.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.77
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$79.88
|
|
|
BEVACIZUMAB 25 MG/ML INTRAVITREAL INJ [4080972]
|
Facility
OP
|
$239.08
|
|
|
Service Code
|
CPT C9257
|
| Hospital Charge Code |
1722041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$179.31 |
| Rate for Payer: Adventist Health Commercial |
$47.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$35.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$98.94
|
| Rate for Payer: Blue Shield of California Commercial |
$148.47
|
| Rate for Payer: Blue Shield of California EPN |
$140.34
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Senior |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$153.01
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.69
|
| Rate for Payer: Heritage Provider Network Senior |
$110.69
|
| Rate for Payer: Humana Medicare |
$1.85
|
| Rate for Payer: IEHP Medicare Advantage |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.33
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.04
|
| Rate for Payer: TriValley Medical Group Senior |
$1.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$79.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$1.85
|
|
|
BEVACIZUMAB 25 MG/ML TOPICAL [4081093]
|
Facility
IP
|
$239.08
|
|
|
Service Code
|
NDC 9994-0810-93
|
| Hospital Charge Code |
NDC4081093
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.27 |
| Max. Negotiated Rate |
$179.31 |
| Rate for Payer: Adventist Health Commercial |
$47.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.25
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$161.86
|
| Rate for Payer: Heritage Provider Network Senior |
$161.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.77
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
|
|
BEVACIZUMAB 25 MG/ML TOPICAL [4081093]
|
Facility
OP
|
$239.08
|
|
|
Service Code
|
NDC 9994-0810-93
|
| Hospital Charge Code |
NDC4081093
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.27 |
| Max. Negotiated Rate |
$203.22 |
| Rate for Payer: Adventist Health Commercial |
$47.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$127.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$203.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$131.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$179.31
|
| Rate for Payer: Blue Shield of California Commercial |
$148.47
|
| Rate for Payer: Blue Shield of California EPN |
$140.34
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$155.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$203.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$203.22
|
| Rate for Payer: Dignity Health Senior |
$203.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$155.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$147.99
|
| Rate for Payer: Heritage Provider Network Senior |
$147.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$115.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.77
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$203.22
|
| Rate for Payer: Vantage Medical Group Senior |
$203.22
|
|
|
BEVACIZUMAB 25 MG/ML TOPICAL [4081093]
|
Facility
IP
|
$239.08
|
|
|
Service Code
|
NDC 50242-060-01
|
| Hospital Charge Code |
1722041
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.27 |
| Max. Negotiated Rate |
$179.31 |
| Rate for Payer: Adventist Health Commercial |
$47.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.25
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$161.86
|
| Rate for Payer: Heritage Provider Network Senior |
$161.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.77
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
|
|
BEVACIZUMAB 25 MG/ML TOPICAL [4081093]
|
Facility
OP
|
$239.08
|
|
|
Service Code
|
NDC 50242-060-01
|
| Hospital Charge Code |
1722041
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.27 |
| Max. Negotiated Rate |
$203.22 |
| Rate for Payer: Adventist Health Commercial |
$47.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$127.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$203.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$131.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$179.31
|
| Rate for Payer: Blue Shield of California Commercial |
$148.47
|
| Rate for Payer: Blue Shield of California EPN |
$140.34
|
| Rate for Payer: Cash Price |
$107.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$155.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$203.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$203.22
|
| Rate for Payer: Dignity Health Senior |
$203.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$155.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$147.99
|
| Rate for Payer: Heritage Provider Network Senior |
$147.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$115.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.77
|
| Rate for Payer: Multiplan Commercial |
$179.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$203.22
|
| Rate for Payer: Vantage Medical Group Senior |
$203.22
|
|
|
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [225272]
|
Facility
OP
|
$209.32
|
|
|
Service Code
|
NDC 55513-206-01
|
| Hospital Charge Code |
NDG225272A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.89 |
| Max. Negotiated Rate |
$177.92 |
| Rate for Payer: Adventist Health Commercial |
$41.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$111.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$143.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$177.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$115.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$156.99
|
| Rate for Payer: Blue Shield of California Commercial |
$129.99
|
| Rate for Payer: Blue Shield of California EPN |
$122.87
|
| Rate for Payer: Cash Price |
$94.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$177.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$177.92
|
| Rate for Payer: Dignity Health Senior |
$177.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$96.92
|
| Rate for Payer: Heritage Provider Network Senior |
$96.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$100.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$37.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.33
|
| Rate for Payer: Multiplan Commercial |
$156.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$76.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$69.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$177.92
|
| Rate for Payer: Vantage Medical Group Senior |
$177.92
|
|
|
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [225272]
|
Facility
IP
|
$209.32
|
|
|
Service Code
|
NDC 55513-206-01
|
| Hospital Charge Code |
NDG225272A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.89 |
| Max. Negotiated Rate |
$156.99 |
| Rate for Payer: Adventist Health Commercial |
$41.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$143.80
|
| Rate for Payer: Cash Price |
$94.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$141.71
|
| Rate for Payer: Heritage Provider Network Senior |
$141.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$37.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.33
|
| Rate for Payer: Multiplan Commercial |
$156.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$76.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$69.93
|
|
|
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [225272]
|
Facility
OP
|
$209.32
|
|
|
Service Code
|
NDC 55513-207-01
|
| Hospital Charge Code |
NDG225272B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.89 |
| Max. Negotiated Rate |
$177.92 |
| Rate for Payer: Adventist Health Commercial |
$41.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$111.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$143.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$177.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$115.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$156.99
|
| Rate for Payer: Blue Shield of California Commercial |
$129.99
|
| Rate for Payer: Blue Shield of California EPN |
$122.87
|
| Rate for Payer: Cash Price |
$94.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$177.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$177.92
|
| Rate for Payer: Dignity Health Senior |
$177.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$96.92
|
| Rate for Payer: Heritage Provider Network Senior |
$96.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$100.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$37.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.33
|
| Rate for Payer: Multiplan Commercial |
$156.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$76.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$69.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$177.92
|
| Rate for Payer: Vantage Medical Group Senior |
$177.92
|
|
