|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT. [40814135]
|
Facility
|
OP
|
$855.36
|
|
|
Service Code
|
CPT J9218
|
| Hospital Charge Code |
1756590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.74 |
| Max. Negotiated Rate |
$641.52 |
| Rate for Payer: Adventist Health Commercial |
$171.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$27.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$587.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$184.09
|
| Rate for Payer: Blue Shield of California Commercial |
$51.73
|
| Rate for Payer: Blue Shield of California EPN |
$51.73
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$393.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.12
|
| Rate for Payer: Dignity Health Senior |
$15.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$547.43
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$396.03
|
| Rate for Payer: Heritage Provider Network Senior |
$396.03
|
| Rate for Payer: Humana Medicare |
$13.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.32
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$342.14
|
| Rate for Payer: TriValley Medical Group Senior |
$342.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$311.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$285.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: Vantage Medical Group Senior |
$13.74
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT. [40814135]
|
Facility
|
IP
|
$855.36
|
|
|
Service Code
|
CPT J9218
|
| Hospital Charge Code |
1756590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.82 |
| Max. Negotiated Rate |
$641.52 |
| Rate for Payer: Adventist Health Commercial |
$171.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$587.63
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$393.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$461.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$579.08
|
| Rate for Payer: Heritage Provider Network Senior |
$579.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.84
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$311.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$285.78
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21045]
|
Facility
|
IP
|
$7,008.31
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1720692
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,268.50 |
| Max. Negotiated Rate |
$5,256.23 |
| Rate for Payer: Adventist Health Commercial |
$1,401.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,814.71
|
| Rate for Payer: Cash Price |
$3,153.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,223.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,784.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,744.63
|
| Rate for Payer: Heritage Provider Network Senior |
$4,744.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,268.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,752.08
|
| Rate for Payer: Multiplan Commercial |
$5,256.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,555.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,341.48
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21045]
|
Facility
|
OP
|
$7,008.31
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1720692
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$5,256.23 |
| Rate for Payer: Adventist Health Commercial |
$1,401.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$357.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,814.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$226.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$199.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,146.50
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$3,153.74
|
| Rate for Payer: Cash Price |
$3,153.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,223.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$271.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$199.43
|
| Rate for Payer: Dignity Health Senior |
$199.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,485.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$181.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,244.85
|
| Rate for Payer: Heritage Provider Network Senior |
$3,244.85
|
| Rate for Payer: Humana Medicare |
$181.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$289.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$181.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$344.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,268.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$213.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,752.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$228.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$228.44
|
| Rate for Payer: Multiplan Commercial |
$5,256.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,803.32
|
| Rate for Payer: TriValley Medical Group Senior |
$2,803.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,555.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,341.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$271.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Vantage Medical Group Senior |
$181.30
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]
|
Facility
|
OP
|
$1,626.08
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1721163
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$1,219.56 |
| Rate for Payer: Adventist Health Commercial |
$325.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$357.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,117.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$226.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$199.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,146.50
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$731.74
|
| Rate for Payer: Cash Price |
$731.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$748.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$271.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$199.43
|
| Rate for Payer: Dignity Health Senior |
$199.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,040.69
|
| Rate for Payer: EPIC Health Plan Medicare |
$181.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$752.88
|
| Rate for Payer: Heritage Provider Network Senior |
$752.88
|
| Rate for Payer: Humana Medicare |
$181.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$289.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$181.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$344.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$294.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$213.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$406.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$228.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$228.44
|
| Rate for Payer: Multiplan Commercial |
$1,219.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$650.43
|
| Rate for Payer: TriValley Medical Group Senior |
$650.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$592.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$543.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$271.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Vantage Medical Group Senior |
$181.30
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]
|
Facility
|
IP
|
$1,626.08
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1721163
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$294.32 |
| Max. Negotiated Rate |
$1,219.56 |
| Rate for Payer: Adventist Health Commercial |
$325.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,117.12
|
| Rate for Payer: Cash Price |
$731.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$748.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$878.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,100.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1,100.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$294.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$406.52
|
| Rate for Payer: Multiplan Commercial |
$1,219.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$592.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$543.27
|
|
|
LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT [21108]
|
Facility
|
OP
|
$9,344.44
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1720911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$7,008.33 |
| Rate for Payer: Adventist Health Commercial |
$1,868.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$357.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,419.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$226.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$199.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,146.50
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$4,205.00
|
| Rate for Payer: Cash Price |
$4,205.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,298.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$271.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$199.43
|
| Rate for Payer: Dignity Health Senior |
$199.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,980.44
|
| Rate for Payer: EPIC Health Plan Medicare |
$181.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,326.48
|
| Rate for Payer: Heritage Provider Network Senior |
$4,326.48
|
| Rate for Payer: Humana Medicare |
$181.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$289.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$181.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$344.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,691.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$213.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,336.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$228.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$228.44
|
| Rate for Payer: Multiplan Commercial |
$7,008.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,737.78
|
| Rate for Payer: TriValley Medical Group Senior |
$3,737.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,406.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,121.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$271.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Vantage Medical Group Senior |
$181.30
|
|
|
LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT [21108]
|
Facility
|
IP
|
$9,344.44
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1720911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,691.34 |
| Max. Negotiated Rate |
$7,008.33 |
| Rate for Payer: Adventist Health Commercial |
$1,868.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,419.63
|
| Rate for Payer: Cash Price |
$4,205.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,298.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,046.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,326.19
|
| Rate for Payer: Heritage Provider Network Senior |
$6,326.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,691.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,336.11
|
| Rate for Payer: Multiplan Commercial |
$7,008.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,406.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,121.98
|
|
|
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [13691]
|
Facility
|
IP
|
$1,960.39
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
1721031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$354.83 |
| Max. Negotiated Rate |
$1,470.29 |
| Rate for Payer: Adventist Health Commercial |
$392.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,346.79
|
| Rate for Payer: Cash Price |
$882.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$901.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,058.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,327.18
|
| Rate for Payer: Heritage Provider Network Senior |
$1,327.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$354.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$490.10
|
| Rate for Payer: Multiplan Commercial |
$1,470.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$714.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$654.97
|
|
|
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [13691]
|
Facility
|
OP
|
$1,960.39
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
1721031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$354.83 |
| Max. Negotiated Rate |
$3,843.64 |
| Rate for Payer: Adventist Health Commercial |
$392.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,843.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,346.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,955.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,721.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,721.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$960.05
|
| Rate for Payer: Blue Shield of California Commercial |
$1,586.98
|
| Rate for Payer: Blue Shield of California EPN |
$1,586.98
|
| Rate for Payer: Cash Price |
$882.18
|
| Rate for Payer: Cash Price |
$882.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$901.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,346.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,721.06
|
| Rate for Payer: Dignity Health Senior |
$1,721.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,254.65
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,564.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$907.66
|
| Rate for Payer: Heritage Provider Network Senior |
$907.66
|
| Rate for Payer: Humana Medicare |
$1,564.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2,447.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,564.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,972.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$354.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,846.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$490.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,971.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,971.40
|
| Rate for Payer: Multiplan Commercial |
$1,470.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$784.16
|
| Rate for Payer: TriValley Medical Group Senior |
$784.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$714.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$654.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,346.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,721.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1,564.60
|
|
|
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]
|
Facility
|
IP
|
$542.03
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1721162
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.11 |
| Max. Negotiated Rate |
$406.52 |
| Rate for Payer: Adventist Health Commercial |
$108.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$372.37
|
| Rate for Payer: Cash Price |
$243.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$249.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$292.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$366.95
|
| Rate for Payer: Heritage Provider Network Senior |
$366.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.51
|
| Rate for Payer: Multiplan Commercial |
$406.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$197.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$181.09
|
|
|
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]
|
Facility
|
OP
|
$542.03
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1721162
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.11 |
| Max. Negotiated Rate |
$1,146.50 |
| Rate for Payer: Adventist Health Commercial |
$108.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$357.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$372.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$226.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$199.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,146.50
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$243.91
|
| Rate for Payer: Cash Price |
$243.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$249.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$271.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$199.43
|
| Rate for Payer: Dignity Health Senior |
$199.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$346.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$181.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$250.96
|
| Rate for Payer: Heritage Provider Network Senior |
$250.96
|
| Rate for Payer: Humana Medicare |
$181.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$289.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$181.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$344.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$213.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$228.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$228.44
|
| Rate for Payer: Multiplan Commercial |
$406.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$216.81
|
| Rate for Payer: TriValley Medical Group Senior |
$216.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$197.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$181.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$271.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Vantage Medical Group Senior |
$181.30
|
|
|
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT [187503]
|
Facility
|
OP
|
$2,336.11
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
ERX187503
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$1,752.08 |
| Rate for Payer: Adventist Health Commercial |
$467.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$357.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,604.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$226.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$199.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,146.50
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$1,051.25
|
| Rate for Payer: Cash Price |
$1,051.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,074.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$271.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$199.43
|
| Rate for Payer: Dignity Health Senior |
$199.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,495.11
|
| Rate for Payer: EPIC Health Plan Medicare |
$181.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,081.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1,081.62
|
| Rate for Payer: Humana Medicare |
$181.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$289.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$181.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$344.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$422.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$213.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$584.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$228.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$228.44
|
| Rate for Payer: Multiplan Commercial |
$1,752.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$934.44
|
| Rate for Payer: TriValley Medical Group Senior |
$934.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$851.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$780.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$271.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Vantage Medical Group Senior |
$181.30
|
|
|
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT [187503]
|
Facility
|
IP
|
$2,336.11
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
ERX187503
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$422.84 |
| Max. Negotiated Rate |
$1,752.08 |
| Rate for Payer: Adventist Health Commercial |
$467.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,604.91
|
| Rate for Payer: Cash Price |
$1,051.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,074.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,261.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,581.55
|
| Rate for Payer: Heritage Provider Network Senior |
$1,581.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$422.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$584.03
|
| Rate for Payer: Multiplan Commercial |
$1,752.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$851.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$780.49
|
|
|
LEUPROLIDE 7.5 MG (PED) INTRAMUSCULAR KIT [27123]
|
Facility
|
IP
|
$2,358.36
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1720544
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$426.86 |
| Max. Negotiated Rate |
$1,768.77 |
| Rate for Payer: Adventist Health Commercial |
$471.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,620.19
|
| Rate for Payer: Cash Price |
$1,061.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,084.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,273.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,596.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1,596.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$426.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$589.59
|
| Rate for Payer: Multiplan Commercial |
$1,768.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$859.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$787.93
|
|
|
LEUPROLIDE 7.5 MG (PED) INTRAMUSCULAR KIT [27123]
|
Facility
|
OP
|
$2,358.36
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1720544
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$1,768.77 |
| Rate for Payer: Adventist Health Commercial |
$471.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$357.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,620.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$226.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$199.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,146.50
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$1,061.26
|
| Rate for Payer: Cash Price |
$1,061.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,084.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$271.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$199.43
|
| Rate for Payer: Dignity Health Senior |
$199.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,509.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$181.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,091.92
|
| Rate for Payer: Heritage Provider Network Senior |
$1,091.92
|
| Rate for Payer: Humana Medicare |
$181.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$289.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$181.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$344.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$426.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$213.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$589.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$228.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$228.44
|
| Rate for Payer: Multiplan Commercial |
$1,768.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$943.34
|
| Rate for Payer: TriValley Medical Group Senior |
$943.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$859.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$787.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$271.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Vantage Medical Group Senior |
$181.30
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [153492]
|
Facility
|
IP
|
$14,016.85
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
ERX153492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,537.05 |
| Max. Negotiated Rate |
$10,512.64 |
| Rate for Payer: Adventist Health Commercial |
$2,803.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9,629.58
|
| Rate for Payer: Cash Price |
$6,307.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6,447.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,569.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$9,489.41
|
| Rate for Payer: Heritage Provider Network Senior |
$9,489.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,537.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,504.21
|
| Rate for Payer: Multiplan Commercial |
$10,512.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5,110.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,683.03
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [153492]
|
Facility
|
OP
|
$14,016.85
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
ERX153492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$10,512.64 |
| Rate for Payer: Adventist Health Commercial |
$2,803.37
|
| Rate for Payer: Aetna of CA Gatekeeper |
$357.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9,629.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$226.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$199.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,146.50
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$6,307.58
|
| Rate for Payer: Cash Price |
$6,307.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6,447.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$271.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$199.43
|
| Rate for Payer: Dignity Health Senior |
$199.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,970.78
|
| Rate for Payer: EPIC Health Plan Medicare |
$181.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,489.80
|
| Rate for Payer: Heritage Provider Network Senior |
$6,489.80
|
| Rate for Payer: Humana Medicare |
$181.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$289.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$181.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$344.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,537.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$213.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,504.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$228.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$228.44
|
| Rate for Payer: Multiplan Commercial |
$10,512.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,606.74
|
| Rate for Payer: TriValley Medical Group Senior |
$5,606.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5,110.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,683.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$271.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Vantage Medical Group Senior |
$181.30
|
|
|
LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 0093-4148-45
|
| Hospital Charge Code |
1781108
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0093-4148-45
|
| Hospital Charge Code |
1781108
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
|
LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154435]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
CPT J1953
|
| Hospital Charge Code |
NDG154435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
|
|
LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154435]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
CPT J1953
|
| Hospital Charge Code |
NDG154435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$7.05 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.57
|
| Rate for Payer: Dignity Health Senior |
$0.11
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 31722-574-47
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 50383-241-16
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.13
|
| 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 |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: Dignity Health Senior |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| 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 |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 60432-831-16
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
