|
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION [10249]
|
Facility
|
OP
|
$129.05
|
|
|
Service Code
|
CPT J9208
|
| Hospital Charge Code |
1755703
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.36 |
| Max. Negotiated Rate |
$282.02 |
| Rate for Payer: Adventist Health Commercial |
$25.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$88.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$109.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$70.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$96.79
|
| 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 |
$58.07
|
| Rate for Payer: Cash Price |
$58.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$59.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$109.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$109.69
|
| Rate for Payer: Dignity Health Senior |
$109.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$82.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.75
|
| Rate for Payer: Heritage Provider Network Senior |
$59.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$62.20
|
| 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: TriValley Medical Group Commercial |
$51.62
|
| Rate for Payer: TriValley Medical Group Senior |
$51.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$47.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$43.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$109.69
|
| Rate for Payer: Vantage Medical Group Senior |
$109.69
|
|
|
ILOPROST 10 MCG/ML SOLUTION FOR NEBULIZATION [40413]
|
Facility
|
IP
|
$161.64
|
|
|
Service Code
|
NDC 66215-302-00
|
| Hospital Charge Code |
1744129
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.26 |
| Max. Negotiated Rate |
$121.23 |
| Rate for Payer: Adventist Health Commercial |
$32.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$111.05
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$87.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$109.43
|
| Rate for Payer: Heritage Provider Network Senior |
$109.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.41
|
| Rate for Payer: Multiplan Commercial |
$121.23
|
|
|
ILOPROST 10 MCG/ML SOLUTION FOR NEBULIZATION [40413]
|
Facility
|
OP
|
$161.64
|
|
|
Service Code
|
NDC 66215-302-30
|
| Hospital Charge Code |
1744129
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.26 |
| Max. Negotiated Rate |
$137.39 |
| Rate for Payer: Adventist Health Commercial |
$32.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$86.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$111.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$137.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$88.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$121.23
|
| Rate for Payer: Blue Shield of California Commercial |
$100.38
|
| Rate for Payer: Blue Shield of California EPN |
$94.88
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$105.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$137.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$137.39
|
| Rate for Payer: Dignity Health Senior |
$137.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$103.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$100.06
|
| Rate for Payer: Heritage Provider Network Senior |
$100.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$77.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.41
|
| Rate for Payer: Multiplan Commercial |
$121.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$64.66
|
| Rate for Payer: TriValley Medical Group Senior |
$64.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$137.39
|
| Rate for Payer: Vantage Medical Group Senior |
$137.39
|
|
|
ILOPROST 10 MCG/ML SOLUTION FOR NEBULIZATION [40413]
|
Facility
|
IP
|
$161.64
|
|
|
Service Code
|
NDC 66215-302-30
|
| Hospital Charge Code |
1744129
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.26 |
| Max. Negotiated Rate |
$121.23 |
| Rate for Payer: Adventist Health Commercial |
$32.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$111.05
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$87.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$109.43
|
| Rate for Payer: Heritage Provider Network Senior |
$109.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.41
|
| Rate for Payer: Multiplan Commercial |
$121.23
|
|
|
ILOPROST 10 MCG/ML SOLUTION FOR NEBULIZATION [40413]
|
Facility
|
OP
|
$161.64
|
|
|
Service Code
|
NDC 66215-302-00
|
| Hospital Charge Code |
1744129
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.26 |
| Max. Negotiated Rate |
$137.39 |
| Rate for Payer: Adventist Health Commercial |
$32.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$86.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$111.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$137.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$88.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$121.23
|
| Rate for Payer: Blue Shield of California Commercial |
$100.38
|
| Rate for Payer: Blue Shield of California EPN |
$94.88
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$105.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$137.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$137.39
|
| Rate for Payer: Dignity Health Senior |
$137.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$103.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$100.06
|
| Rate for Payer: Heritage Provider Network Senior |
$100.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$77.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.41
|
| Rate for Payer: Multiplan Commercial |
$121.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$64.66
|
| Rate for Payer: TriValley Medical Group Senior |
$64.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$137.39
|
| Rate for Payer: Vantage Medical Group Senior |
$137.39
|
|
|
ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]
|
Facility
|
OP
|
$161.64
|
|
|
Service Code
|
NDC 66215-303-30
|
| Hospital Charge Code |
1744134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.26 |
| Max. Negotiated Rate |
$137.39 |
| Rate for Payer: Adventist Health Commercial |
$32.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$86.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$111.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$137.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$88.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$121.23
|
| Rate for Payer: Blue Shield of California Commercial |
$100.38
|
| Rate for Payer: Blue Shield of California EPN |
$94.88
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$105.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$137.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$137.39
|
| Rate for Payer: Dignity Health Senior |
$137.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$103.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$100.06
|
| Rate for Payer: Heritage Provider Network Senior |
$100.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$77.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.41
|
| Rate for Payer: Multiplan Commercial |
$121.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$64.66
|
| Rate for Payer: TriValley Medical Group Senior |
$64.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$137.39
|
| Rate for Payer: Vantage Medical Group Senior |
$137.39
|
|
|
ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]
|
Facility
|
IP
|
$161.64
|
|
|
Service Code
|
NDC 66215-303-00
|
| Hospital Charge Code |
1744134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.26 |
| Max. Negotiated Rate |
$121.23 |
| Rate for Payer: Adventist Health Commercial |
$32.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$111.05
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$87.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$109.43
|
| Rate for Payer: Heritage Provider Network Senior |
$109.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.41
|
| Rate for Payer: Multiplan Commercial |
$121.23
|
|
|
ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]
|
Facility
|
OP
|
$161.64
|
|
|
Service Code
|
NDC 66215-303-00
|
| Hospital Charge Code |
1744134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.26 |
| Max. Negotiated Rate |
$137.39 |
| Rate for Payer: Adventist Health Commercial |
$32.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$86.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$111.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$137.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$88.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$121.23
|
| Rate for Payer: Blue Shield of California Commercial |
$100.38
|
| Rate for Payer: Blue Shield of California EPN |
$94.88
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$105.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$137.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$137.39
|
| Rate for Payer: Dignity Health Senior |
$137.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$103.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$100.06
|
| Rate for Payer: Heritage Provider Network Senior |
$100.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$77.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.41
|
| Rate for Payer: Multiplan Commercial |
$121.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$64.66
|
| Rate for Payer: TriValley Medical Group Senior |
$64.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$137.39
|
| Rate for Payer: Vantage Medical Group Senior |
$137.39
|
|
|
ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]
|
Facility
|
IP
|
$161.64
|
|
|
Service Code
|
NDC 66215-303-30
|
| Hospital Charge Code |
1744134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.26 |
| Max. Negotiated Rate |
$121.23 |
| Rate for Payer: Adventist Health Commercial |
$32.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$111.05
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$87.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$109.43
|
| Rate for Payer: Heritage Provider Network Senior |
$109.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.41
|
| Rate for Payer: Multiplan Commercial |
$121.23
|
|
|
IMATINIB 100 MG TABLET [32979]
|
Facility
|
IP
|
$4.55
|
|
|
Service Code
|
CPT S0088
|
| Hospital Charge Code |
1711843
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.41 |
| Rate for Payer: Adventist Health Commercial |
$0.91
|
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Adventist Health Commercial |
$10.72
|
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.01
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$3.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1.33
|
| Rate for Payer: Heritage Provider Network Senior |
$36.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.40
|
| Rate for Payer: Multiplan Commercial |
$3.41
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$40.20
|
|
|
IMATINIB 100 MG TABLET [32979]
|
Facility
|
OP
|
$53.60
|
|
|
Service Code
|
CPT S0088
|
| Hospital Charge Code |
1711843
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.06 |
| Max. Negotiated Rate |
$134.18 |
| Rate for Payer: Adventist Health Commercial |
$10.72
|
| Rate for Payer: Adventist Health Commercial |
$0.91
|
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$45.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$29.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$40.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$134.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$134.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$134.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$134.18
|
| Rate for Payer: Blue Shield of California Commercial |
$33.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California Commercial |
$2.83
|
| Rate for Payer: Blue Shield of California EPN |
$31.46
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.86
|
| Rate for Payer: Blue Shield of California EPN |
$2.67
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$45.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.56
|
| Rate for Payer: Dignity Health Senior |
$3.87
|
| Rate for Payer: Dignity Health Senior |
$1.67
|
| Rate for Payer: Dignity Health Senior |
$1.25
|
| Rate for Payer: Dignity Health Senior |
$45.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.82
|
| Rate for Payer: Heritage Provider Network Senior |
$1.22
|
| Rate for Payer: Heritage Provider Network Senior |
$33.18
|
| Rate for Payer: Heritage Provider Network Senior |
$2.82
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$25.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$3.41
|
| Rate for Payer: Multiplan Commercial |
$40.20
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$21.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.59
|
| Rate for Payer: TriValley Medical Group Senior |
$1.82
|
| Rate for Payer: TriValley Medical Group Senior |
$0.79
|
| Rate for Payer: TriValley Medical Group Senior |
$0.59
|
| Rate for Payer: TriValley Medical Group Senior |
$21.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.87
|
| Rate for Payer: Vantage Medical Group Senior |
$1.25
|
| Rate for Payer: Vantage Medical Group Senior |
$3.87
|
| Rate for Payer: Vantage Medical Group Senior |
$1.67
|
| Rate for Payer: Vantage Medical Group Senior |
$45.56
|
|
|
IMATINIB 400 MG TABLET [36092]
|
Facility
|
IP
|
$16.38
|
|
|
Service Code
|
CPT S0088
|
| Hospital Charge Code |
1711842
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$12.28 |
| Rate for Payer: Adventist Health Commercial |
$3.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.25
|
| Rate for Payer: Cash Price |
$7.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.09
|
| Rate for Payer: Heritage Provider Network Senior |
$11.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.10
|
| Rate for Payer: Multiplan Commercial |
$12.28
|
|
|
IMATINIB 400 MG TABLET [36092]
|
Facility
|
OP
|
$16.38
|
|
|
Service Code
|
CPT S0088
|
| Hospital Charge Code |
1711842
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$134.18 |
| Rate for Payer: Adventist Health Commercial |
$3.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$134.18
|
| Rate for Payer: Blue Shield of California Commercial |
$10.17
|
| Rate for Payer: Blue Shield of California EPN |
$9.62
|
| Rate for Payer: Cash Price |
$7.37
|
| Rate for Payer: Cash Price |
$7.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.92
|
| Rate for Payer: Dignity Health Senior |
$13.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.14
|
| Rate for Payer: Heritage Provider Network Senior |
$10.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.10
|
| Rate for Payer: Multiplan Commercial |
$12.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.55
|
| Rate for Payer: TriValley Medical Group Senior |
$6.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.92
|
| Rate for Payer: Vantage Medical Group Senior |
$13.92
|
|
|
IMIPENEM-CILASTATIN 250 MG INTRAVENOUS SOLUTION [9602]
|
Facility
|
IP
|
$17.99
|
|
|
Service Code
|
CPT J0743
|
| Hospital Charge Code |
ERX9602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$13.49 |
| Rate for Payer: Adventist Health Commercial |
$3.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.36
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.18
|
| Rate for Payer: Heritage Provider Network Senior |
$12.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$13.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.01
|
|
|
IMIPENEM-CILASTATIN 250 MG INTRAVENOUS SOLUTION [9602]
|
Facility
|
OP
|
$17.99
|
|
|
Service Code
|
CPT J0743
|
| Hospital Charge Code |
ERX9602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$30.34 |
| Rate for Payer: Adventist Health Commercial |
$3.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.34
|
| Rate for Payer: Blue Shield of California Commercial |
$10.29
|
| Rate for Payer: Blue Shield of California EPN |
$10.29
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.29
|
| Rate for Payer: Dignity Health Senior |
$15.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.33
|
| Rate for Payer: Heritage Provider Network Senior |
$8.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$13.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.20
|
| Rate for Payer: TriValley Medical Group Senior |
$7.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.29
|
| Rate for Payer: Vantage Medical Group Senior |
$15.29
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]
|
Facility
|
IP
|
$32.82
|
|
|
Service Code
|
CPT J0743
|
| Hospital Charge Code |
1753116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$24.62 |
| Rate for Payer: Adventist Health Commercial |
$6.56
|
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.55
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cash Price |
$14.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.22
|
| Rate for Payer: Heritage Provider Network Senior |
$24.36
|
| Rate for Payer: Heritage Provider Network Senior |
$22.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$24.62
|
| Rate for Payer: Multiplan Commercial |
$26.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.02
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]
|
Facility
|
OP
|
$32.82
|
|
|
Service Code
|
CPT J0743
|
| Hospital Charge Code |
1753116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$30.34 |
| Rate for Payer: Adventist Health Commercial |
$6.56
|
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.34
|
| Rate for Payer: Blue Shield of California Commercial |
$10.29
|
| Rate for Payer: Blue Shield of California Commercial |
$10.29
|
| Rate for Payer: Blue Shield of California EPN |
$10.29
|
| Rate for Payer: Blue Shield of California EPN |
$10.29
|
| Rate for Payer: Cash Price |
$14.77
|
| Rate for Payer: Cash Price |
$14.77
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.90
|
| Rate for Payer: Dignity Health Senior |
$27.90
|
| Rate for Payer: Dignity Health Senior |
$30.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.20
|
| Rate for Payer: Heritage Provider Network Senior |
$15.20
|
| Rate for Payer: Heritage Provider Network Senior |
$16.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.20
|
| Rate for Payer: Multiplan Commercial |
$26.98
|
| Rate for Payer: Multiplan Commercial |
$24.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.39
|
| Rate for Payer: TriValley Medical Group Senior |
$14.39
|
| Rate for Payer: TriValley Medical Group Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.58
|
| Rate for Payer: Vantage Medical Group Senior |
$27.90
|
| Rate for Payer: Vantage Medical Group Senior |
$30.58
|
|
|
IMIPRAMINE 10 MG TABLET [3860]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 69315-133-01
|
| Hospital Charge Code |
1711106
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| 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 |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| 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 |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
IMIPRAMINE 10 MG TABLET [3860]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 69315-133-01
|
| Hospital Charge Code |
1711106
|
|
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 Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| 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
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 69315-134-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 0781-1764-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: Dignity Health Senior |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 49884-055-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Senior |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 0781-1764-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 49884-055-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 69315-134-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Senior |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
