|
IBUPROFEN 800 MG TABLET [3845]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 64380-807-06
|
| Hospital Charge Code |
1711405
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
IBUPROFEN 800 MG TABLET [3845]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 60687-468-11
|
| Hospital Charge Code |
1711405
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
IBUPROFEN 800 MG TABLET [3845]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 60687-468-11
|
| Hospital Charge Code |
1711405
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
IBUPROFEN 800 MG TABLET [3845]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 67877-321-01
|
| Hospital Charge Code |
1711405
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
IBUPROFEN 800 MG TABLET [3845]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 0904-5855-60
|
| Hospital Charge Code |
1711405
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
IBUPROFEN 800 MG TABLET [3845]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 0904-5855-61
|
| Hospital Charge Code |
1711405
|
|
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
|
|
|
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [76780]
|
Facility
|
IP
|
$273.74
|
|
|
Service Code
|
CPT J1741
|
| Hospital Charge Code |
1721169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.55 |
| Max. Negotiated Rate |
$205.30 |
| Rate for Payer: Adventist Health Commercial |
$54.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$188.06
|
| Rate for Payer: Cash Price |
$123.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$125.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$147.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$185.32
|
| Rate for Payer: Heritage Provider Network Senior |
$185.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.44
|
| Rate for Payer: Multiplan Commercial |
$205.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$99.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$91.46
|
|
|
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [76780]
|
Facility
|
OP
|
$273.74
|
|
|
Service Code
|
CPT J1741
|
| Hospital Charge Code |
1721169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$232.68 |
| Rate for Payer: Adventist Health Commercial |
$54.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$188.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$232.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$150.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$205.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.67
|
| Rate for Payer: Blue Shield of California Commercial |
$2.72
|
| Rate for Payer: Blue Shield of California EPN |
$2.72
|
| Rate for Payer: Cash Price |
$123.18
|
| Rate for Payer: Cash Price |
$123.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$125.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$232.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$232.68
|
| Rate for Payer: Dignity Health Senior |
$232.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$175.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$126.74
|
| Rate for Payer: Heritage Provider Network Senior |
$126.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$131.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.44
|
| Rate for Payer: Multiplan Commercial |
$205.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$109.50
|
| Rate for Payer: TriValley Medical Group Senior |
$109.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$99.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$91.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$232.68
|
| Rate for Payer: Vantage Medical Group Senior |
$232.68
|
|
|
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION [16156]
|
Facility
|
OP
|
$65.86
|
|
|
Service Code
|
CPT J1742
|
| Hospital Charge Code |
1722011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.92 |
| Max. Negotiated Rate |
$722.66 |
| Rate for Payer: Adventist Health Commercial |
$13.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$722.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$45.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$237.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$209.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$209.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$490.76
|
| Rate for Payer: Blue Shield of California Commercial |
$304.27
|
| Rate for Payer: Blue Shield of California EPN |
$304.27
|
| Rate for Payer: Cash Price |
$29.64
|
| Rate for Payer: Cash Price |
$29.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$285.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$209.27
|
| Rate for Payer: Dignity Health Senior |
$209.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$190.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.49
|
| Rate for Payer: Heritage Provider Network Senior |
$30.49
|
| Rate for Payer: Humana Medicare |
$190.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$190.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$361.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$224.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$239.71
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$239.71
|
| Rate for Payer: Multiplan Commercial |
$49.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$26.34
|
| Rate for Payer: TriValley Medical Group Senior |
$26.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$285.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$209.27
|
| Rate for Payer: Vantage Medical Group Senior |
$190.24
|
|
|
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION [16156]
|
Facility
|
IP
|
$65.86
|
|
|
Service Code
|
CPT J1742
|
| Hospital Charge Code |
1722011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.92 |
| Max. Negotiated Rate |
$49.40 |
| Rate for Payer: Adventist Health Commercial |
$13.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$45.25
|
| Rate for Payer: Cash Price |
$29.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.59
|
| Rate for Payer: Heritage Provider Network Senior |
$44.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.46
|
| Rate for Payer: Multiplan Commercial |
$49.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.00
|
|
|
IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION [22144]
|
Facility
|
OP
|
$12.94
|
|
|
Service Code
|
CPT J9211
|
| Hospital Charge Code |
NDG22144A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$874.73 |
| Rate for Payer: Adventist Health Commercial |
$2.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$84.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$874.73
|
| Rate for Payer: Blue Shield of California Commercial |
$52.77
|
| Rate for Payer: Blue Shield of California EPN |
$52.77
|
| Rate for Payer: Cash Price |
$5.82
|
| Rate for Payer: Cash Price |
$5.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.00
|
| Rate for Payer: Dignity Health Senior |
$11.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.99
|
| Rate for Payer: Heritage Provider Network Senior |
$5.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.24
|
| Rate for Payer: Multiplan Commercial |
$9.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.18
|
| Rate for Payer: TriValley Medical Group Senior |
$5.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.00
|
| Rate for Payer: Vantage Medical Group Senior |
$11.00
|
|
|
IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION [22144]
|
Facility
|
IP
|
$16.07
|
|
|
Service Code
|
CPT J9211
|
| Hospital Charge Code |
NDG22144B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: Adventist Health Commercial |
$3.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.04
|
| Rate for Payer: Cash Price |
$7.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.88
|
| Rate for Payer: Heritage Provider Network Senior |
$10.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.02
|
| Rate for Payer: Multiplan Commercial |
$12.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.37
|
|
|
IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION [22144]
|
Facility
|
OP
|
$16.07
|
|
|
Service Code
|
CPT J9211
|
| Hospital Charge Code |
NDG22144B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$874.73 |
| Rate for Payer: Adventist Health Commercial |
$3.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$84.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$874.73
|
| Rate for Payer: Blue Shield of California Commercial |
$52.77
|
| Rate for Payer: Blue Shield of California EPN |
$52.77
|
| Rate for Payer: Cash Price |
$7.23
|
| Rate for Payer: Cash Price |
$7.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.66
|
| Rate for Payer: Dignity Health Senior |
$13.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.44
|
| Rate for Payer: Heritage Provider Network Senior |
$7.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.02
|
| Rate for Payer: Multiplan Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.43
|
| Rate for Payer: TriValley Medical Group Senior |
$6.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.66
|
| Rate for Payer: Vantage Medical Group Senior |
$13.66
|
|
|
IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION [22144]
|
Facility
|
OP
|
$12.42
|
|
|
Service Code
|
CPT J9211
|
| Hospital Charge Code |
1755541
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$874.73 |
| Rate for Payer: Adventist Health Commercial |
$2.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$84.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$874.73
|
| Rate for Payer: Blue Shield of California Commercial |
$52.77
|
| Rate for Payer: Blue Shield of California EPN |
$52.77
|
| Rate for Payer: Cash Price |
$5.59
|
| Rate for Payer: Cash Price |
$5.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.56
|
| Rate for Payer: Dignity Health Senior |
$10.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.75
|
| Rate for Payer: Heritage Provider Network Senior |
$5.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.10
|
| Rate for Payer: Multiplan Commercial |
$9.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.97
|
| Rate for Payer: TriValley Medical Group Senior |
$4.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.56
|
| Rate for Payer: Vantage Medical Group Senior |
$10.56
|
|
|
IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION [22144]
|
Facility
|
IP
|
$12.42
|
|
|
Service Code
|
CPT J9211
|
| Hospital Charge Code |
1755541
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$9.32 |
| Rate for Payer: Adventist Health Commercial |
$2.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.53
|
| Rate for Payer: Cash Price |
$5.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.41
|
| Rate for Payer: Heritage Provider Network Senior |
$8.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.10
|
| Rate for Payer: Multiplan Commercial |
$9.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.15
|
|
|
IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION [22144]
|
Facility
|
IP
|
$12.94
|
|
|
Service Code
|
CPT J9211
|
| Hospital Charge Code |
NDG22144A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Adventist Health Commercial |
$2.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.89
|
| Rate for Payer: Cash Price |
$5.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.76
|
| Rate for Payer: Heritage Provider Network Senior |
$8.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.24
|
| Rate for Payer: Multiplan Commercial |
$9.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.32
|
|
|
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [211698]
|
Facility
|
IP
|
$56.61
|
|
|
Service Code
|
CPT J3590
|
| Hospital Charge Code |
NDG211698
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$42.46 |
| Rate for Payer: Adventist Health Commercial |
$11.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.89
|
| Rate for Payer: Cash Price |
$25.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.32
|
| Rate for Payer: Heritage Provider Network Senior |
$38.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.15
|
| Rate for Payer: Multiplan Commercial |
$42.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.91
|
|
|
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [211698]
|
Facility
|
OP
|
$56.61
|
|
|
Service Code
|
CPT J3590
|
| Hospital Charge Code |
NDG211698
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$48.12 |
| Rate for Payer: Adventist Health Commercial |
$11.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$30.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$48.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42.46
|
| Rate for Payer: Blue Shield of California Commercial |
$35.15
|
| Rate for Payer: Blue Shield of California EPN |
$33.23
|
| Rate for Payer: Cash Price |
$25.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.12
|
| Rate for Payer: Dignity Health Senior |
$48.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.21
|
| Rate for Payer: Heritage Provider Network Senior |
$26.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$27.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.15
|
| Rate for Payer: Multiplan Commercial |
$42.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.64
|
| Rate for Payer: TriValley Medical Group Senior |
$22.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.12
|
| Rate for Payer: Vantage Medical Group Senior |
$48.12
|
|
|
IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION [87925]
|
Facility
|
OP
|
$2.20
|
|
|
Service Code
|
CPT J9208
|
| Hospital Charge Code |
NDG87925
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$282.02 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$282.02
|
| Rate for Payer: Blue Shield of California Commercial |
$37.48
|
| Rate for Payer: Blue Shield of California EPN |
$37.48
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.87
|
| Rate for Payer: Dignity Health Senior |
$1.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.88
|
| Rate for Payer: TriValley Medical Group Senior |
$0.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.87
|
| Rate for Payer: Vantage Medical Group Senior |
$1.87
|
|
|
IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION [87925]
|
Facility
|
IP
|
$2.20
|
|
|
Service Code
|
CPT J9208
|
| Hospital Charge Code |
NDG87925
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.51
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.49
|
| Rate for Payer: Heritage Provider Network Senior |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.74
|
|
|
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION [10248]
|
Facility
|
OP
|
$69.66
|
|
|
Service Code
|
CPT J9208
|
| Hospital Charge Code |
1755702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.61 |
| Max. Negotiated Rate |
$282.02 |
| Rate for Payer: Adventist Health Commercial |
$13.93
|
| Rate for Payer: Adventist Health Commercial |
$8.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$47.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$37.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$59.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$52.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$33.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$282.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$282.02
|
| Rate for Payer: Blue Shield of California Commercial |
$37.48
|
| Rate for Payer: Blue Shield of California Commercial |
$37.48
|
| Rate for Payer: Blue Shield of California EPN |
$37.48
|
| Rate for Payer: Blue Shield of California EPN |
$37.48
|
| Rate for Payer: Cash Price |
$19.84
|
| Rate for Payer: Cash Price |
$19.84
|
| Rate for Payer: Cash Price |
$31.35
|
| Rate for Payer: Cash Price |
$31.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$37.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$59.21
|
| Rate for Payer: Dignity Health Senior |
$59.21
|
| Rate for Payer: Dignity Health Senior |
$37.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.41
|
| Rate for Payer: Heritage Provider Network Senior |
$20.41
|
| Rate for Payer: Heritage Provider Network Senior |
$32.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$33.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.02
|
| Rate for Payer: Multiplan Commercial |
$52.24
|
| Rate for Payer: Multiplan Commercial |
$33.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$27.86
|
| Rate for Payer: TriValley Medical Group Senior |
$17.64
|
| Rate for Payer: TriValley Medical Group Senior |
$27.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$25.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$37.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$59.21
|
| Rate for Payer: Vantage Medical Group Senior |
$59.21
|
| Rate for Payer: Vantage Medical Group Senior |
$37.48
|
|
|
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION [10248]
|
Facility
|
IP
|
$44.09
|
|
|
Service Code
|
CPT J9208
|
| Hospital Charge Code |
1755702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.98 |
| Max. Negotiated Rate |
$33.07 |
| Rate for Payer: Adventist Health Commercial |
$8.82
|
| Rate for Payer: Adventist Health Commercial |
$13.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$47.86
|
| Rate for Payer: Cash Price |
$19.84
|
| Rate for Payer: Cash Price |
$31.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.16
|
| Rate for Payer: Heritage Provider Network Senior |
$47.16
|
| Rate for Payer: Heritage Provider Network Senior |
$29.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.42
|
| Rate for Payer: Multiplan Commercial |
$33.07
|
| Rate for Payer: Multiplan Commercial |
$52.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$25.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.73
|
|
|
IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION [87926]
|
Facility
|
OP
|
$2.15
|
|
|
Service Code
|
CPT J9208
|
| Hospital Charge Code |
NDG87926
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$282.02 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$282.02
|
| Rate for Payer: Blue Shield of California Commercial |
$37.48
|
| Rate for Payer: Blue Shield of California EPN |
$37.48
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.83
|
| Rate for Payer: Dignity Health Senior |
$1.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Senior |
$0.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: Vantage Medical Group Senior |
$1.83
|
|
|
IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION [87926]
|
Facility
|
IP
|
$2.15
|
|
|
Service Code
|
CPT J9208
|
| Hospital Charge Code |
NDG87926
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.48
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.46
|
| Rate for Payer: Heritage Provider Network Senior |
$1.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.72
|
|
|
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION [10249]
|
Facility
|
IP
|
$129.05
|
|
|
Service Code
|
CPT J9208
|
| Hospital Charge Code |
1755703
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.36 |
| Max. Negotiated Rate |
$96.79 |
| Rate for Payer: Adventist Health Commercial |
$25.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$88.66
|
| Rate for Payer: Cash Price |
$58.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$59.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$87.37
|
| Rate for Payer: Heritage Provider Network Senior |
$87.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.26
|
| Rate for Payer: Multiplan Commercial |
$96.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$47.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$43.12
|
|
