|
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
|
|
|
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION [216412]
|
Facility
IP
|
$114.00
|
|
|
Service Code
|
CPT J0565
|
| Hospital Charge Code |
NDG216412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.63 |
| Max. Negotiated Rate |
$85.50 |
| Rate for Payer: Adventist Health Commercial |
$22.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$78.32
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$77.18
|
| Rate for Payer: Heritage Provider Network Senior |
$77.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.50
|
| Rate for Payer: Multiplan Commercial |
$85.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$41.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.09
|
|
|
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION [216412]
|
Facility
OP
|
$114.00
|
|
|
Service Code
|
CPT J0565
|
| Hospital Charge Code |
NDG216412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.63 |
| Max. Negotiated Rate |
$97.92 |
| Rate for Payer: Adventist Health Commercial |
$22.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$97.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$78.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$49.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$43.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$43.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$81.17
|
| Rate for Payer: Blue Shield of California Commercial |
$38.76
|
| Rate for Payer: Blue Shield of California EPN |
$38.76
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.84
|
| Rate for Payer: Dignity Health Senior |
$43.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.96
|
| Rate for Payer: EPIC Health Plan Medicare |
$39.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.78
|
| Rate for Payer: Heritage Provider Network Senior |
$52.78
|
| Rate for Payer: Humana Medicare |
$39.86
|
| Rate for Payer: IEHP Medi-Cal |
$69.14
|
| Rate for Payer: IEHP Medicare Advantage |
$39.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$75.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$47.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$50.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$50.22
|
| Rate for Payer: Multiplan Commercial |
$85.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.84
|
| Rate for Payer: TriValley Medical Group Senior |
$39.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$41.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$59.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.84
|
| Rate for Payer: Vantage Medical Group Senior |
$39.86
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
IP
|
$0.60
|
|
|
Service Code
|
NDC 41616-485-83
|
| Hospital Charge Code |
1710869
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| 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 |
$0.45
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
IP
|
$0.35
|
|
|
Service Code
|
NDC 0904-6019-46
|
| Hospital Charge Code |
1710869
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
IP
|
$0.91
|
|
|
Service Code
|
NDC 16729-023-10
|
| Hospital Charge Code |
1710869
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
OP
|
$0.35
|
|
|
Service Code
|
NDC 0904-6019-46
|
| Hospital Charge Code |
1710869
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Senior |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
OP
|
$0.60
|
|
|
Service Code
|
NDC 41616-485-83
|
| Hospital Charge Code |
1710869
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Senior |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| 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 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 |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
OP
|
$0.91
|
|
|
Service Code
|
NDC 16729-023-10
|
| Hospital Charge Code |
1710869
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Senior |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
BICARB HEMODIALYSIS SOLN WITHOUT CALCIUM NO 16 POT 4 MEQ-MAG 1.5 MEQ/L [121436]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 24571-111-06
|
| Hospital Charge Code |
1771296
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
BICARB HEMODIALYSIS SOLN WITHOUT CALCIUM NO 16 POT 4 MEQ-MAG 1.5 MEQ/L [121436]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 24571-111-06
|
| Hospital Charge Code |
1771296
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
BICARBONATE DIALYSIS SOLN WITHOUT CALCIUM NO15 POT 4 MEQ-MAG 1.2 MEQ/L [121260]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 24571-114-06
|
| Hospital Charge Code |
NDG121260
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
BICARBONATE DIALYSIS SOLN WITHOUT CALCIUM NO15 POT 4 MEQ-MAG 1.2 MEQ/L [121260]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 24571-114-06
|
| Hospital Charge Code |
NDG121260
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
BICARBONATE HEMODIALYSIS SOLUTION NO.2 K 2 MEQ-CA 3.5 MEQ-MG 1 MEQ/L [120070]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
CPT A4706
|
| Hospital Charge Code |
NDG120070
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
BICARBONATE HEMODIALYSIS SOLUTION NO.2 K 2 MEQ-CA 3.5 MEQ-MG 1 MEQ/L [120070]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
CPT A4706
|
| Hospital Charge Code |
NDG120070
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$14.59 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
BICARBONATE HEMODIALYSIS SOLUTION NO.9 K 4 MEQ-CA 2.5 MEQ-MG 1.5 MEQ/L [100176]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 24571-105-06
|
| Hospital Charge Code |
1771276
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
BICARBONATE HEMODIALYSIS SOLUTION NO.9 K 4 MEQ-CA 2.5 MEQ-MG 1.5 MEQ/L [100176]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 24571-105-06
|
| Hospital Charge Code |
1771276
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET [221141]
|
Facility
IP
|
$151.81
|
|
|
Service Code
|
NDC 61958-2501-1
|
| Hospital Charge Code |
ERX221141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.48 |
| Max. Negotiated Rate |
$113.86 |
| Rate for Payer: Adventist Health Commercial |
$30.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$104.29
|
| Rate for Payer: Cash Price |
$68.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$102.78
|
| Rate for Payer: Heritage Provider Network Senior |
$102.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.95
|
| Rate for Payer: Multiplan Commercial |
$113.86
|
|
|
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET [221141]
|
Facility
OP
|
$151.81
|
|
|
Service Code
|
NDC 61958-2501-1
|
| Hospital Charge Code |
ERX221141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.48 |
| Max. Negotiated Rate |
$129.04 |
| Rate for Payer: Adventist Health Commercial |
$30.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$81.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$104.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$129.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$83.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$113.86
|
| Rate for Payer: Blue Shield of California Commercial |
$94.27
|
| Rate for Payer: Blue Shield of California EPN |
$89.11
|
| Rate for Payer: Cash Price |
$68.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$98.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$129.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$129.04
|
| Rate for Payer: Dignity Health Senior |
$129.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$93.97
|
| Rate for Payer: Heritage Provider Network Senior |
$93.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$73.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.95
|
| Rate for Payer: Multiplan Commercial |
$113.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$129.04
|
| Rate for Payer: Vantage Medical Group Senior |
$129.04
|
|
|
BIMATOPROST 0.01 % EYE DROPS [105410]
|
Facility
OP
|
$114.92
|
|
|
Service Code
|
NDC 0023-3205-03
|
| Hospital Charge Code |
NDG105410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$97.68 |
| Rate for Payer: Adventist Health Commercial |
$22.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$61.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$78.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$97.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$63.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$86.19
|
| Rate for Payer: Blue Shield of California Commercial |
$71.37
|
| Rate for Payer: Blue Shield of California EPN |
$67.46
|
| Rate for Payer: Cash Price |
$51.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$74.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$97.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$97.68
|
| Rate for Payer: Dignity Health Senior |
$97.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.14
|
| Rate for Payer: Heritage Provider Network Senior |
$71.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$55.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.73
|
| Rate for Payer: Multiplan Commercial |
$86.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$97.68
|
| Rate for Payer: Vantage Medical Group Senior |
$97.68
|
|
|
BIMATOPROST 0.01 % EYE DROPS [105410]
|
Facility
IP
|
$114.92
|
|
|
Service Code
|
NDC 0023-3205-03
|
| Hospital Charge Code |
NDG105410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$86.19 |
| Rate for Payer: Adventist Health Commercial |
$22.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$78.95
|
| Rate for Payer: Cash Price |
$51.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$77.80
|
| Rate for Payer: Heritage Provider Network Senior |
$77.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.73
|
| Rate for Payer: Multiplan Commercial |
$86.19
|
|
|
Biopsy, bone, open; deep (eg, humeral shaft, ischium, femoral shaft)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 20245
|
| Min. Negotiated Rate |
$328.72 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5,325.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,905.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,550.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,325.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,905.29
|
| Rate for Payer: Dignity Health Senior |
$3,550.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,550.26
|
| Rate for Payer: Humana Medicare |
$3,550.26
|
| Rate for Payer: IEHP Medi-Cal |
$328.72
|
| Rate for Payer: IEHP Medicare Advantage |
$3,550.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6,745.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,189.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,473.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,473.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,905.29
|
| Rate for Payer: TriValley Medical Group Senior |
$3,550.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,325.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,905.29
|
| Rate for Payer: Vantage Medical Group Senior |
$3,550.26
|
|
|
Biopsy, bone, open; superficial (eg, sternum, spinous process, rib, patella, olecranon process, calcaneus, tarsal, metatarsal, carpal, metacarpal, phalanx)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 20240
|
| Min. Negotiated Rate |
$197.46 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5,325.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,905.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,550.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,325.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,905.29
|
| Rate for Payer: Dignity Health Senior |
$3,550.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,550.26
|
| Rate for Payer: Humana Medicare |
$3,550.26
|
| Rate for Payer: IEHP Medi-Cal |
$197.46
|
| Rate for Payer: IEHP Medicare Advantage |
$3,550.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6,745.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,189.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,473.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,473.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,905.29
|
| Rate for Payer: TriValley Medical Group Senior |
$3,550.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,325.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,905.29
|
| Rate for Payer: Vantage Medical Group Senior |
$3,550.26
|
|
|
Biopsy of anorectal wall, anal approach (eg, congenital megacolon)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 45100
|
| Min. Negotiated Rate |
$263.09 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5,262.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,858.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,508.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,262.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,858.96
|
| Rate for Payer: Dignity Health Senior |
$3,508.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,508.15
|
| Rate for Payer: Humana Medicare |
$3,508.15
|
| Rate for Payer: IEHP Medi-Cal |
$263.09
|
| Rate for Payer: IEHP Medicare Advantage |
$3,508.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6,665.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,139.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,420.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,420.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,858.96
|
| Rate for Payer: TriValley Medical Group Senior |
$3,508.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,262.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,858.96
|
| Rate for Payer: Vantage Medical Group Senior |
$3,508.15
|
|
|
Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 57500
|
| Min. Negotiated Rate |
$63.24 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,506.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,104.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,004.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,506.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,104.87
|
| Rate for Payer: Dignity Health Senior |
$1,004.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,004.43
|
| Rate for Payer: Humana Medicare |
$1,004.43
|
| Rate for Payer: IEHP Medi-Cal |
$63.24
|
| Rate for Payer: IEHP Medicare Advantage |
$1,004.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,908.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,185.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,265.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,265.58
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,104.87
|
| Rate for Payer: TriValley Medical Group Senior |
$1,004.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,506.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,104.87
|
| Rate for Payer: Vantage Medical Group Senior |
$1,004.43
|
|
