|
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION [221652]
|
Facility
|
OP
|
$20.29
|
|
|
Service Code
|
NDC 0023-6082-01
|
| Hospital Charge Code |
NDG199344
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$17.25 |
| Rate for Payer: Adventist Health Commercial |
$4.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.22
|
| Rate for Payer: Blue Shield of California Commercial |
$12.60
|
| Rate for Payer: Blue Shield of California EPN |
$11.91
|
| Rate for Payer: Cash Price |
$9.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.25
|
| Rate for Payer: Dignity Health Senior |
$17.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.39
|
| Rate for Payer: Heritage Provider Network Senior |
$9.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.07
|
| Rate for Payer: Multiplan Commercial |
$15.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.12
|
| Rate for Payer: TriValley Medical Group Senior |
$8.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.25
|
| Rate for Payer: Vantage Medical Group Senior |
$17.25
|
|
|
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION [29132]
|
Facility
|
IP
|
$13.86
|
|
|
Service Code
|
CPT J1756
|
| Hospital Charge Code |
1720948
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Adventist Health Commercial |
$2.77
|
| Rate for Payer: Adventist Health Commercial |
$1.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.07
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cash Price |
$3.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.98
|
| Rate for Payer: Heritage Provider Network Senior |
$5.98
|
| Rate for Payer: Heritage Provider Network Senior |
$9.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$10.40
|
| Rate for Payer: Multiplan Commercial |
$6.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.63
|
|
|
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION [29132]
|
Facility
|
OP
|
$8.83
|
|
|
Service Code
|
CPT J1756
|
| Hospital Charge Code |
1720948
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$7.51 |
| Rate for Payer: Adventist Health Commercial |
$1.77
|
| Rate for Payer: Adventist Health Commercial |
$2.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cash Price |
$3.97
|
| Rate for Payer: Cash Price |
$3.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.51
|
| Rate for Payer: Dignity Health Senior |
$7.51
|
| Rate for Payer: Dignity Health Senior |
$11.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.42
|
| Rate for Payer: Heritage Provider Network Senior |
$6.42
|
| Rate for Payer: Heritage Provider Network Senior |
$4.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Multiplan Commercial |
$6.62
|
| Rate for Payer: Multiplan Commercial |
$10.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.53
|
| Rate for Payer: TriValley Medical Group Senior |
$5.54
|
| Rate for Payer: TriValley Medical Group Senior |
$3.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.51
|
| Rate for Payer: Vantage Medical Group Senior |
$7.51
|
| Rate for Payer: Vantage Medical Group Senior |
$11.78
|
|
|
IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION [187493]
|
Facility
|
IP
|
$11.52
|
|
|
Service Code
|
CPT J1756
|
| Hospital Charge Code |
NDG187493
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Adventist Health Commercial |
$2.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.52
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.38
|
| Rate for Payer: Heritage Provider Network Senior |
$9.38
|
| Rate for Payer: Heritage Provider Network Senior |
$7.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Multiplan Commercial |
$8.64
|
| Rate for Payer: Multiplan Commercial |
$10.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.85
|
|
|
IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION [187493]
|
Facility
|
OP
|
$13.86
|
|
|
Service Code
|
CPT J1756
|
| Hospital Charge Code |
NDG187493
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$11.78 |
| Rate for Payer: Adventist Health Commercial |
$2.77
|
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.78
|
| Rate for Payer: Dignity Health Senior |
$11.78
|
| Rate for Payer: Dignity Health Senior |
$9.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.33
|
| Rate for Payer: Heritage Provider Network Senior |
$5.33
|
| Rate for Payer: Heritage Provider Network Senior |
$6.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$10.40
|
| Rate for Payer: Multiplan Commercial |
$8.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.54
|
| Rate for Payer: TriValley Medical Group Senior |
$4.61
|
| Rate for Payer: TriValley Medical Group Senior |
$5.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.78
|
| Rate for Payer: Vantage Medical Group Senior |
$11.78
|
| Rate for Payer: Vantage Medical Group Senior |
$9.79
|
|
|
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION [227445]
|
Facility
|
OP
|
$180.81
|
|
|
Service Code
|
NDC 0024-0656-01
|
| Hospital Charge Code |
NDG227445A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.73 |
| Max. Negotiated Rate |
$153.69 |
| Rate for Payer: Adventist Health Commercial |
$36.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$96.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$124.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$153.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$99.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$135.61
|
| Rate for Payer: Blue Shield of California Commercial |
$112.28
|
| Rate for Payer: Blue Shield of California EPN |
$106.14
|
| Rate for Payer: Cash Price |
$81.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$83.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$153.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$153.69
|
| Rate for Payer: Dignity Health Senior |
$153.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$115.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$83.72
|
| Rate for Payer: Heritage Provider Network Senior |
$83.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$87.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.20
|
| Rate for Payer: Multiplan Commercial |
$135.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$72.32
|
| Rate for Payer: TriValley Medical Group Senior |
$72.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$65.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$60.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$153.69
|
| Rate for Payer: Vantage Medical Group Senior |
$153.69
|
|
|
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION [227445]
|
Facility
|
IP
|
$180.81
|
|
|
Service Code
|
NDC 0024-0656-01
|
| Hospital Charge Code |
NDG227445A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.73 |
| Max. Negotiated Rate |
$135.61 |
| Rate for Payer: Adventist Health Commercial |
$36.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$124.22
|
| Rate for Payer: Cash Price |
$81.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$83.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$122.41
|
| Rate for Payer: Heritage Provider Network Senior |
$122.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.20
|
| Rate for Payer: Multiplan Commercial |
$135.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$65.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$60.41
|
|
|
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION [227445]
|
Facility
|
IP
|
$180.81
|
|
|
Service Code
|
NDC 0024-0654-01
|
| Hospital Charge Code |
NDG227445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.73 |
| Max. Negotiated Rate |
$135.61 |
| Rate for Payer: Adventist Health Commercial |
$36.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$124.22
|
| Rate for Payer: Cash Price |
$81.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$83.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$122.41
|
| Rate for Payer: Heritage Provider Network Senior |
$122.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.20
|
| Rate for Payer: Multiplan Commercial |
$135.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$65.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$60.41
|
|
|
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION [227445]
|
Facility
|
OP
|
$180.81
|
|
|
Service Code
|
NDC 0024-0654-01
|
| Hospital Charge Code |
NDG227445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.73 |
| Max. Negotiated Rate |
$153.69 |
| Rate for Payer: Adventist Health Commercial |
$36.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$96.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$124.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$153.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$99.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$135.61
|
| Rate for Payer: Blue Shield of California Commercial |
$112.28
|
| Rate for Payer: Blue Shield of California EPN |
$106.14
|
| Rate for Payer: Cash Price |
$81.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$83.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$153.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$153.69
|
| Rate for Payer: Dignity Health Senior |
$153.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$115.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$83.72
|
| Rate for Payer: Heritage Provider Network Senior |
$83.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$87.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.20
|
| Rate for Payer: Multiplan Commercial |
$135.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$72.32
|
| Rate for Payer: TriValley Medical Group Senior |
$72.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$65.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$60.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$153.69
|
| Rate for Payer: Vantage Medical Group Senior |
$153.69
|
|
|
ISAVUCONAZONIUM SULFATE 186 MG CAPSULE [209331]
|
Facility
|
OP
|
$128.43
|
|
|
Service Code
|
NDC 0469-0520-02
|
| Hospital Charge Code |
ERX209331
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.25 |
| Max. Negotiated Rate |
$109.17 |
| Rate for Payer: Adventist Health Commercial |
$25.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$68.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$88.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$109.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$70.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$96.32
|
| Rate for Payer: Blue Shield of California Commercial |
$79.76
|
| Rate for Payer: Blue Shield of California EPN |
$75.39
|
| Rate for Payer: Cash Price |
$57.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$83.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$109.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$109.17
|
| Rate for Payer: Dignity Health Senior |
$109.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$82.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.50
|
| Rate for Payer: Heritage Provider Network Senior |
$79.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$61.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.11
|
| Rate for Payer: Multiplan Commercial |
$96.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$51.37
|
| Rate for Payer: TriValley Medical Group Senior |
$51.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$109.17
|
| Rate for Payer: Vantage Medical Group Senior |
$109.17
|
|
|
ISAVUCONAZONIUM SULFATE 186 MG CAPSULE [209331]
|
Facility
|
IP
|
$128.43
|
|
|
Service Code
|
NDC 0469-0520-02
|
| Hospital Charge Code |
ERX209331
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.25 |
| Max. Negotiated Rate |
$96.32 |
| Rate for Payer: Adventist Health Commercial |
$25.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$88.23
|
| Rate for Payer: Cash Price |
$57.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$86.95
|
| Rate for Payer: Heritage Provider Network Senior |
$86.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.11
|
| Rate for Payer: Multiplan Commercial |
$96.32
|
|
|
ISONIAZID 100 MG TABLET [4026]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0555-0066-02
|
| Hospital Charge Code |
1710461
|
|
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 Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| 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
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
ISONIAZID 100 MG TABLET [4026]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0555-0066-02
|
| Hospital Charge Code |
1710461
|
|
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 |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| 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
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 0555-0071-01
|
| Hospital Charge Code |
1710467
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 0555-0071-01
|
| Hospital Charge Code |
1710467
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
IP
|
$1.24
|
|
|
Service Code
|
NDC 51079-083-01
|
| Hospital Charge Code |
1710467
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Senior |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 0555-0071-02
|
| Hospital Charge Code |
1710467
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| 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 |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| 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 |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| 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 |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
NDC 51079-083-01
|
| Hospital Charge Code |
1710467
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.93
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: Dignity Health Senior |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Senior |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 0555-0071-02
|
| Hospital Charge Code |
1710467
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| 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 |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
ISONIAZID 50 MG/5 ML ORAL SOLUTION [4025]
|
Facility
|
OP
|
$0.74
|
|
|
Service Code
|
NDC 46287-009-01
|
| Hospital Charge Code |
1715021
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.63
|
| Rate for Payer: Dignity Health Senior |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Senior |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.63
|
| Rate for Payer: Vantage Medical Group Senior |
$0.63
|
|
|
ISONIAZID 50 MG/5 ML ORAL SOLUTION [4025]
|
Facility
|
IP
|
$0.74
|
|
|
Service Code
|
NDC 46287-009-01
|
| Hospital Charge Code |
1715021
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.51
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION [110292]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
NDC 0548-9502-00
|
| Hospital Charge Code |
1720174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.98
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.50
|
| Rate for Payer: Heritage Provider Network Senior |
$32.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
|
|
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION [110292]
|
Facility
|
OP
|
$33.60
|
|
|
Service Code
|
NDC 23155-661-42
|
| Hospital Charge Code |
1720174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$28.56 |
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.20
|
| Rate for Payer: Blue Shield of California Commercial |
$20.87
|
| Rate for Payer: Blue Shield of California EPN |
$19.72
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.56
|
| Rate for Payer: Dignity Health Senior |
$28.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.80
|
| Rate for Payer: Heritage Provider Network Senior |
$20.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.44
|
| Rate for Payer: TriValley Medical Group Senior |
$13.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.56
|
| Rate for Payer: Vantage Medical Group Senior |
$28.56
|
|
|
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION [110292]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
NDC 0548-9502-00
|
| Hospital Charge Code |
1720174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$40.80 |
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.00
|
| Rate for Payer: Blue Shield of California Commercial |
$29.81
|
| Rate for Payer: Blue Shield of California EPN |
$28.18
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: Dignity Health Senior |
$40.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.71
|
| Rate for Payer: Heritage Provider Network Senior |
$29.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.20
|
| Rate for Payer: TriValley Medical Group Senior |
$19.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
|
|
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION [110292]
|
Facility
|
IP
|
$33.60
|
|
|
Service Code
|
NDC 23155-661-31
|
| Hospital Charge Code |
1720174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$25.20 |
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.08
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.75
|
| Rate for Payer: Heritage Provider Network Senior |
$22.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
|
