|
Blepharoplasty, upper eyelid; with excessive skin weighting down lid
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15823
|
| Min. Negotiated Rate |
$2,278.49 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
Bone graft, any donor area; major or large
|
Facility
|
OP
|
$16,983.21
|
|
|
Service Code
|
CPT 20902
|
| Min. Negotiated Rate |
$4,857.00 |
| Max. Negotiated Rate |
$16,983.21 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,938.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,832.38
|
| Rate for Payer: Dignity Health Senior |
$8,938.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$8,938.53
|
| Rate for Payer: Humana Medicare |
$8,938.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,938.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16,983.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10,547.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,262.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11,262.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,832.38
|
| Rate for Payer: TriValley Medical Group Senior |
$8,938.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Vantage Medical Group Senior |
$8,938.53
|
|
|
Bone graft, any donor area; minor or small (eg, dowel or button)
|
Facility
|
OP
|
$16,983.21
|
|
|
Service Code
|
CPT 20900
|
| Min. Negotiated Rate |
$300.85 |
| Max. Negotiated Rate |
$16,983.21 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,938.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,832.38
|
| Rate for Payer: Dignity Health Senior |
$8,938.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$8,938.53
|
| Rate for Payer: Humana Medicare |
$8,938.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$300.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,938.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16,983.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10,547.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,262.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11,262.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,832.38
|
| Rate for Payer: TriValley Medical Group Senior |
$8,938.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Vantage Medical Group Senior |
$8,938.53
|
|
|
Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 20962
|
| Min. Negotiated Rate |
$710.30 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$710.30
|
|
|
BORIC ACID (BULK) POWDER [1131]
|
Facility
|
IP
|
$0.95
|
|
|
Service Code
|
NDC 3877900649
|
| Hospital Charge Code |
NDG1131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
|
|
BORIC ACID (BULK) POWDER [1131]
|
Facility
|
OP
|
$0.95
|
|
|
Service Code
|
NDC 3877900649
|
| Hospital Charge Code |
NDG1131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.81
|
| Rate for Payer: Dignity Health Senior |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Senior |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Senior |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Vantage Medical Group Senior |
$0.81
|
|
|
BORIC ACID (BULK) POWDER [1131]
|
Facility
|
IP
|
$0.95
|
|
|
Service Code
|
NDC 3877900648
|
| Hospital Charge Code |
NDG1131A
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
|
|
BORIC ACID (BULK) POWDER [1131]
|
Facility
|
OP
|
$0.95
|
|
|
Service Code
|
NDC 3877900648
|
| Hospital Charge Code |
NDG1131A
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.81
|
| Rate for Payer: Dignity Health Senior |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Senior |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Senior |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Vantage Medical Group Senior |
$0.81
|
|
|
BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
NDC 70860-225-10
|
| Hospital Charge Code |
ERX35839
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$128.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$180.00
|
| Rate for Payer: Blue Shield of California Commercial |
$149.04
|
| Rate for Payer: Blue Shield of California EPN |
$140.88
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: Dignity Health Senior |
$204.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$153.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.12
|
| Rate for Payer: Heritage Provider Network Senior |
$111.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$115.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$96.00
|
| Rate for Payer: TriValley Medical Group Senior |
$96.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$80.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
|
|
BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]
|
Facility
|
OP
|
$1,923.60
|
|
|
Service Code
|
NDC 63020-049-01
|
| Hospital Charge Code |
ERX35839
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$348.17 |
| Max. Negotiated Rate |
$1,635.06 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,028.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,321.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,635.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,057.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,442.70
|
| Rate for Payer: Blue Shield of California Commercial |
$1,194.56
|
| Rate for Payer: Blue Shield of California EPN |
$1,129.15
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$884.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,635.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,635.06
|
| Rate for Payer: Dignity Health Senior |
$1,635.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,231.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$890.63
|
| Rate for Payer: Heritage Provider Network Senior |
$890.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$927.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$348.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$480.90
|
| Rate for Payer: Multiplan Commercial |
$1,442.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$769.44
|
| Rate for Payer: TriValley Medical Group Senior |
$769.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$701.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$642.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,635.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1,635.06
|
|
|
BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
NDC 70860-225-10
|
| Hospital Charge Code |
ERX35839
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$129.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$162.48
|
| Rate for Payer: Heritage Provider Network Senior |
$162.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$80.18
|
|
|
BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
NDC 43598-426-60
|
| Hospital Charge Code |
ERX35839
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.30 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Adventist Health Commercial |
$60.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$160.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$206.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$255.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$165.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$225.00
|
| Rate for Payer: Blue Shield of California Commercial |
$186.30
|
| Rate for Payer: Blue Shield of California EPN |
$176.10
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$138.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$255.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$255.00
|
| Rate for Payer: Dignity Health Senior |
$255.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$192.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$138.90
|
| Rate for Payer: Heritage Provider Network Senior |
$138.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$144.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.00
|
| Rate for Payer: Multiplan Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$120.00
|
| Rate for Payer: TriValley Medical Group Senior |
$120.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$109.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$100.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$255.00
|
| Rate for Payer: Vantage Medical Group Senior |
$255.00
|
|
|
BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
NDC 43598-426-60
|
| Hospital Charge Code |
ERX35839
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.30 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Adventist Health Commercial |
$60.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$206.10
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$138.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$203.10
|
| Rate for Payer: Heritage Provider Network Senior |
$203.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.00
|
| Rate for Payer: Multiplan Commercial |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$109.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$100.23
|
|
|
BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]
|
Facility
|
IP
|
$1,923.60
|
|
|
Service Code
|
NDC 63020-049-01
|
| Hospital Charge Code |
ERX35839
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$348.17 |
| Max. Negotiated Rate |
$1,442.70 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,321.51
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$884.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,302.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1,302.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$348.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$480.90
|
| Rate for Payer: Multiplan Commercial |
$1,442.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$701.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$642.67
|
|
|
BORTEZOMIB 3.5 MG INTRAVENOUS POWDER FOR SOLUTION [220799]
|
Facility
|
OP
|
$1,923.58
|
|
|
Service Code
|
CPT J9048
|
| Hospital Charge Code |
ERX220799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.72 |
| Max. Negotiated Rate |
$1,442.68 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$110.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,321.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$60.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$97.93
|
| Rate for Payer: Blue Shield of California Commercial |
$46.72
|
| Rate for Payer: Blue Shield of California EPN |
$46.72
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$884.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.40
|
| Rate for Payer: Dignity Health Senior |
$53.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,231.09
|
| Rate for Payer: EPIC Health Plan Medicare |
$48.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$890.62
|
| Rate for Payer: Heritage Provider Network Senior |
$890.62
|
| Rate for Payer: Humana Medicare |
$48.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$78.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$92.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$348.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$57.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$480.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$61.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$61.17
|
| Rate for Payer: Multiplan Commercial |
$1,442.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$769.43
|
| Rate for Payer: TriValley Medical Group Senior |
$769.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$701.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$642.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.40
|
| Rate for Payer: Vantage Medical Group Senior |
$48.55
|
|
|
BORTEZOMIB 3.5 MG INTRAVENOUS POWDER FOR SOLUTION [220799]
|
Facility
|
IP
|
$1,923.58
|
|
|
Service Code
|
CPT J9048
|
| Hospital Charge Code |
ERX220799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$348.17 |
| Max. Negotiated Rate |
$1,442.68 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,321.50
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$884.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,302.26
|
| Rate for Payer: Heritage Provider Network Senior |
$1,302.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$348.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$480.90
|
| Rate for Payer: Multiplan Commercial |
$1,442.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$701.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$642.67
|
|
|
BORTEZOMIB 3.5 MG IV INJECTION. [408035839]
|
Facility
|
IP
|
$1,923.58
|
|
|
Service Code
|
CPT J9041
|
| Hospital Charge Code |
1755707
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$348.17 |
| Max. Negotiated Rate |
$1,442.68 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,321.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,321.50
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$884.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$884.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,302.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,302.26
|
| Rate for Payer: Heritage Provider Network Senior |
$1,302.26
|
| Rate for Payer: Heritage Provider Network Senior |
$1,302.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$348.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$348.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$480.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$480.90
|
| Rate for Payer: Multiplan Commercial |
$1,442.68
|
| Rate for Payer: Multiplan Commercial |
$1,442.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$701.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$701.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$642.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$642.67
|
|
|
BORTEZOMIB 3.5 MG IV INJECTION. [408035839]
|
Facility
|
OP
|
$1,923.58
|
|
|
Service Code
|
CPT J9041
|
| Hospital Charge Code |
1755707
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$1,442.68 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,321.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,321.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.95
|
| Rate for Payer: Blue Shield of California Commercial |
$7.28
|
| Rate for Payer: Blue Shield of California Commercial |
$7.28
|
| Rate for Payer: Blue Shield of California EPN |
$7.28
|
| Rate for Payer: Blue Shield of California EPN |
$7.28
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$884.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$884.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.15
|
| Rate for Payer: Dignity Health Senior |
$2.15
|
| Rate for Payer: Dignity Health Senior |
$2.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,231.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,231.10
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.96
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$890.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$890.63
|
| Rate for Payer: Heritage Provider Network Senior |
$890.63
|
| Rate for Payer: Heritage Provider Network Senior |
$890.62
|
| Rate for Payer: Humana Medicare |
$1.96
|
| Rate for Payer: Humana Medicare |
$1.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$348.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$348.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$480.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$480.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.47
|
| Rate for Payer: Multiplan Commercial |
$1,442.68
|
| Rate for Payer: Multiplan Commercial |
$1,442.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$769.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$769.43
|
| Rate for Payer: TriValley Medical Group Senior |
$769.44
|
| Rate for Payer: TriValley Medical Group Senior |
$769.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$701.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$701.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$642.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$642.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1.96
|
| Rate for Payer: Vantage Medical Group Senior |
$1.96
|
|
|
BORTEZOMIB 3.5 MG SOLUTION FOR INJECTION SQ [40835839]
|
Facility
|
IP
|
$1,923.60
|
|
|
Service Code
|
CPT J9041
|
| Hospital Charge Code |
ERX40835839
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$348.17 |
| Max. Negotiated Rate |
$1,442.70 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,321.51
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$884.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,302.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1,302.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$348.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$480.90
|
| Rate for Payer: Multiplan Commercial |
$1,442.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$701.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$642.67
|
|
|
BORTEZOMIB 3.5 MG SOLUTION FOR INJECTION SQ [40835839]
|
Facility
|
OP
|
$1,923.60
|
|
|
Service Code
|
CPT J9041
|
| Hospital Charge Code |
ERX40835839
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$1,442.70 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,321.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.95
|
| Rate for Payer: Blue Shield of California Commercial |
$7.28
|
| Rate for Payer: Blue Shield of California EPN |
$7.28
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$884.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.15
|
| Rate for Payer: Dignity Health Senior |
$2.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,231.10
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$890.63
|
| Rate for Payer: Heritage Provider Network Senior |
$890.63
|
| Rate for Payer: Humana Medicare |
$1.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$348.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$480.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.47
|
| Rate for Payer: Multiplan Commercial |
$1,442.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$769.44
|
| Rate for Payer: TriValley Medical Group Senior |
$769.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$701.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$642.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1.96
|
|
|
BOSENTAN 125 MG TABLET [31876]
|
Facility
|
OP
|
$23.26
|
|
|
Service Code
|
NDC 68382-447-14
|
| Hospital Charge Code |
1710988
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.21 |
| Max. Negotiated Rate |
$19.77 |
| Rate for Payer: Adventist Health Commercial |
$4.65
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.44
|
| Rate for Payer: Blue Shield of California Commercial |
$14.44
|
| Rate for Payer: Blue Shield of California EPN |
$13.65
|
| Rate for Payer: Cash Price |
$10.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.77
|
| Rate for Payer: Dignity Health Senior |
$19.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.40
|
| Rate for Payer: Heritage Provider Network Senior |
$14.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.82
|
| Rate for Payer: Multiplan Commercial |
$17.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.30
|
| Rate for Payer: TriValley Medical Group Senior |
$9.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.77
|
| Rate for Payer: Vantage Medical Group Senior |
$19.77
|
|
|
BOSENTAN 125 MG TABLET [31876]
|
Facility
|
IP
|
$23.26
|
|
|
Service Code
|
NDC 68382-447-14
|
| Hospital Charge Code |
1710988
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.21 |
| Max. Negotiated Rate |
$17.44 |
| Rate for Payer: Adventist Health Commercial |
$4.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.98
|
| Rate for Payer: Cash Price |
$10.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.75
|
| Rate for Payer: Heritage Provider Network Senior |
$15.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.82
|
| Rate for Payer: Multiplan Commercial |
$17.44
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
1710987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.11 |
| Max. Negotiated Rate |
$197.74 |
| Rate for Payer: Adventist Health Commercial |
$46.53
|
| Rate for Payer: Aetna of CA Gatekeeper |
$124.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$159.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$197.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$127.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$174.47
|
| Rate for Payer: Blue Shield of California Commercial |
$144.46
|
| Rate for Payer: Blue Shield of California EPN |
$136.55
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$197.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$197.74
|
| Rate for Payer: Dignity Health Senior |
$197.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$148.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$144.00
|
| Rate for Payer: Heritage Provider Network Senior |
$144.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$112.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.16
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$93.05
|
| Rate for Payer: TriValley Medical Group Senior |
$93.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$197.74
|
| Rate for Payer: Vantage Medical Group Senior |
$197.74
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
1710987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.11 |
| Max. Negotiated Rate |
$197.74 |
| Rate for Payer: Adventist Health Commercial |
$46.53
|
| Rate for Payer: Aetna of CA Gatekeeper |
$124.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$159.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$197.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$127.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$174.47
|
| Rate for Payer: Blue Shield of California Commercial |
$144.46
|
| Rate for Payer: Blue Shield of California EPN |
$136.55
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$197.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$197.74
|
| Rate for Payer: Dignity Health Senior |
$197.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$148.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$144.00
|
| Rate for Payer: Heritage Provider Network Senior |
$144.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$112.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.16
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$93.05
|
| Rate for Payer: TriValley Medical Group Senior |
$93.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$197.74
|
| Rate for Payer: Vantage Medical Group Senior |
$197.74
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
1710987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.11 |
| Max. Negotiated Rate |
$174.47 |
| Rate for Payer: Adventist Health Commercial |
$46.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$159.82
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$125.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$157.49
|
| Rate for Payer: Heritage Provider Network Senior |
$157.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.16
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
|
