|
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION [10249]
|
Facility
|
IP
|
$129.05
|
|
|
Service Code
|
HCPCS J9208
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.36 |
| Max. Negotiated Rate |
$96.79 |
| Rate for Payer: Adventist Health Commercial |
$25.81
|
| Rate for Payer: Cash Price |
$70.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$59.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.75
|
| Rate for Payer: Heritage Provider Network Senior |
$59.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.26
|
| Rate for Payer: Multiplan Commercial |
$96.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$46.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.73
|
|
|
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION [10249]
|
Facility
|
OP
|
$129.05
|
|
|
Service Code
|
HCPCS J9208
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.36 |
| Max. Negotiated Rate |
$109.69 |
| Rate for Payer: Adventist Health Commercial |
$25.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$68.98
|
| 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 |
$95.16
|
| 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 |
$70.98
|
| Rate for Payer: Cash Price |
$70.98
|
| 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 |
$24.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$61.56
|
| 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: Molina Healthcare of CA Medi-Cal |
$90.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$90.33
|
| 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 |
$46.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$109.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$109.69
|
| Rate for Payer: Vantage Medical Group Senior |
$109.69
|
|
|
IGG 10 GRAM/100 ML (10 %)-HYALURONIDASE,RECOMB. SUBCUTANEOUS SOLUTION [207472]
|
Facility
|
OP
|
$29.42
|
|
|
Service Code
|
NDC 0944-2512-02
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$25.01 |
| Rate for Payer: Adventist Health Commercial |
$5.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.07
|
| Rate for Payer: Blue Shield of California Commercial |
$17.95
|
| Rate for Payer: Blue Shield of California EPN |
$14.36
|
| Rate for Payer: Cash Price |
$16.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.01
|
| Rate for Payer: Dignity Health Senior |
$25.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.21
|
| Rate for Payer: Heritage Provider Network Senior |
$18.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.59
|
| Rate for Payer: Multiplan Commercial |
$22.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.01
|
| Rate for Payer: Vantage Medical Group Senior |
$25.01
|
|
|
IGG 10 GRAM/100 ML (10 %)-HYALURONIDASE,RECOMB. SUBCUTANEOUS SOLUTION [207472]
|
Facility
|
IP
|
$29.42
|
|
|
Service Code
|
NDC 0944-2512-02
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$22.07 |
| Rate for Payer: Adventist Health Commercial |
$5.88
|
| Rate for Payer: Cash Price |
$16.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.92
|
| Rate for Payer: Heritage Provider Network Senior |
$19.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.36
|
| Rate for Payer: Multiplan Commercial |
$22.07
|
|
|
IGG 20 GRAM/200 ML (10 %)-HYALURONIDASE,RECOMB. SUBCUTANEOUS SOLUTION [207473]
|
Facility
|
IP
|
$29.42
|
|
|
Service Code
|
NDC 0944-2513-02
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$22.07 |
| Rate for Payer: Adventist Health Commercial |
$5.88
|
| Rate for Payer: Cash Price |
$16.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.92
|
| Rate for Payer: Heritage Provider Network Senior |
$19.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.36
|
| Rate for Payer: Multiplan Commercial |
$22.07
|
|
|
IGG 20 GRAM/200 ML (10 %)-HYALURONIDASE,RECOMB. SUBCUTANEOUS SOLUTION [207473]
|
Facility
|
OP
|
$29.42
|
|
|
Service Code
|
NDC 0944-2513-02
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$25.01 |
| Rate for Payer: Adventist Health Commercial |
$5.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.07
|
| Rate for Payer: Blue Shield of California Commercial |
$17.95
|
| Rate for Payer: Blue Shield of California EPN |
$14.36
|
| Rate for Payer: Cash Price |
$16.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.01
|
| Rate for Payer: Dignity Health Senior |
$25.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.21
|
| Rate for Payer: Heritage Provider Network Senior |
$18.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.59
|
| Rate for Payer: Multiplan Commercial |
$22.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.01
|
| Rate for Payer: Vantage Medical Group Senior |
$25.01
|
|
|
IGG 5 GRAM/50 ML (10 %)-HYALURONIDASE,RECOMB. SUBCUTANEOUS SOLUTION [207471]
|
Facility
|
IP
|
$29.42
|
|
|
Service Code
|
NDC 0944-2511-02
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$22.07 |
| Rate for Payer: Adventist Health Commercial |
$5.88
|
| Rate for Payer: Cash Price |
$16.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.92
|
| Rate for Payer: Heritage Provider Network Senior |
$19.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.36
|
| Rate for Payer: Multiplan Commercial |
$22.07
|
|
|
IGG 5 GRAM/50 ML (10 %)-HYALURONIDASE,RECOMB. SUBCUTANEOUS SOLUTION [207471]
|
Facility
|
OP
|
$29.42
|
|
|
Service Code
|
NDC 0944-2511-02
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$25.01 |
| Rate for Payer: Adventist Health Commercial |
$5.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.07
|
| Rate for Payer: Blue Shield of California Commercial |
$17.95
|
| Rate for Payer: Blue Shield of California EPN |
$14.36
|
| Rate for Payer: Cash Price |
$16.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.01
|
| Rate for Payer: Dignity Health Senior |
$25.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.21
|
| Rate for Payer: Heritage Provider Network Senior |
$18.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.59
|
| Rate for Payer: Multiplan Commercial |
$22.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.01
|
| Rate for Payer: Vantage Medical Group Senior |
$25.01
|
|
|
ILOPROST 10 MCG/ML SOLUTION FOR NEBULIZATION [40413]
|
Facility
|
IP
|
$179.92
|
|
|
Service Code
|
NDC 66215-302-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.57 |
| Max. Negotiated Rate |
$134.94 |
| Rate for Payer: Adventist Health Commercial |
$35.98
|
| Rate for Payer: Cash Price |
$98.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$121.81
|
| Rate for Payer: Heritage Provider Network Senior |
$121.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.98
|
| Rate for Payer: Multiplan Commercial |
$134.94
|
|
|
ILOPROST 10 MCG/ML SOLUTION FOR NEBULIZATION [40413]
|
Facility
|
OP
|
$179.90
|
|
|
Service Code
|
NDC 66215-302-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.56 |
| Max. Negotiated Rate |
$152.91 |
| Rate for Payer: Adventist Health Commercial |
$35.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$96.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$123.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$152.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$98.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$134.93
|
| Rate for Payer: Blue Shield of California Commercial |
$109.74
|
| Rate for Payer: Blue Shield of California EPN |
$87.79
|
| Rate for Payer: Cash Price |
$98.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$116.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$152.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$152.91
|
| Rate for Payer: Dignity Health Senior |
$152.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$115.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.36
|
| Rate for Payer: Heritage Provider Network Senior |
$111.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$85.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$125.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$125.93
|
| Rate for Payer: Multiplan Commercial |
$134.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$71.96
|
| Rate for Payer: TriValley Medical Group Senior |
$71.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$89.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$89.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$152.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$152.91
|
| Rate for Payer: Vantage Medical Group Senior |
$152.91
|
|
|
ILOPROST 10 MCG/ML SOLUTION FOR NEBULIZATION [40413]
|
Facility
|
IP
|
$179.90
|
|
|
Service Code
|
NDC 66215-302-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.56 |
| Max. Negotiated Rate |
$134.93 |
| Rate for Payer: Adventist Health Commercial |
$35.98
|
| Rate for Payer: Cash Price |
$98.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$121.79
|
| Rate for Payer: Heritage Provider Network Senior |
$121.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.98
|
| Rate for Payer: Multiplan Commercial |
$134.93
|
|
|
ILOPROST 10 MCG/ML SOLUTION FOR NEBULIZATION [40413]
|
Facility
|
OP
|
$179.92
|
|
|
Service Code
|
NDC 66215-302-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.57 |
| Max. Negotiated Rate |
$152.93 |
| Rate for Payer: Adventist Health Commercial |
$35.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$96.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$123.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$152.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$98.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$134.94
|
| Rate for Payer: Blue Shield of California Commercial |
$109.75
|
| Rate for Payer: Blue Shield of California EPN |
$87.80
|
| Rate for Payer: Cash Price |
$98.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$116.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$152.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$152.93
|
| Rate for Payer: Dignity Health Senior |
$152.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$115.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.37
|
| Rate for Payer: Heritage Provider Network Senior |
$111.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$85.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$125.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$125.94
|
| Rate for Payer: Multiplan Commercial |
$134.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$71.97
|
| Rate for Payer: TriValley Medical Group Senior |
$71.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$89.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$89.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$152.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$152.93
|
| Rate for Payer: Vantage Medical Group Senior |
$152.93
|
|
|
ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]
|
Facility
|
OP
|
$179.92
|
|
|
Service Code
|
NDC 66215-303-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.57 |
| Max. Negotiated Rate |
$152.93 |
| Rate for Payer: Adventist Health Commercial |
$35.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$96.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$123.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$152.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$98.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$134.94
|
| Rate for Payer: Blue Shield of California Commercial |
$109.75
|
| Rate for Payer: Blue Shield of California EPN |
$87.80
|
| Rate for Payer: Cash Price |
$98.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$116.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$152.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$152.93
|
| Rate for Payer: Dignity Health Senior |
$152.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$115.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.37
|
| Rate for Payer: Heritage Provider Network Senior |
$111.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$85.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$125.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$125.94
|
| Rate for Payer: Multiplan Commercial |
$134.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$71.97
|
| Rate for Payer: TriValley Medical Group Senior |
$71.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$89.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$89.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$152.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$152.93
|
| Rate for Payer: Vantage Medical Group Senior |
$152.93
|
|
|
ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]
|
Facility
|
IP
|
$179.92
|
|
|
Service Code
|
NDC 66215-303-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.57 |
| Max. Negotiated Rate |
$134.94 |
| Rate for Payer: Adventist Health Commercial |
$35.98
|
| Rate for Payer: Cash Price |
$98.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$121.81
|
| Rate for Payer: Heritage Provider Network Senior |
$121.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.98
|
| Rate for Payer: Multiplan Commercial |
$134.94
|
|
|
ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]
|
Facility
|
OP
|
$179.90
|
|
|
Service Code
|
NDC 66215-303-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.56 |
| Max. Negotiated Rate |
$152.91 |
| Rate for Payer: Adventist Health Commercial |
$35.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$96.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$123.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$152.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$98.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$134.93
|
| Rate for Payer: Blue Shield of California Commercial |
$109.74
|
| Rate for Payer: Blue Shield of California EPN |
$87.79
|
| Rate for Payer: Cash Price |
$98.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$116.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$152.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$152.91
|
| Rate for Payer: Dignity Health Senior |
$152.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$115.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.36
|
| Rate for Payer: Heritage Provider Network Senior |
$111.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$85.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$125.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$125.93
|
| Rate for Payer: Multiplan Commercial |
$134.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$71.96
|
| Rate for Payer: TriValley Medical Group Senior |
$71.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$89.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$89.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$152.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$152.91
|
| Rate for Payer: Vantage Medical Group Senior |
$152.91
|
|
|
ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]
|
Facility
|
IP
|
$179.90
|
|
|
Service Code
|
NDC 66215-303-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.56 |
| Max. Negotiated Rate |
$134.93 |
| Rate for Payer: Adventist Health Commercial |
$35.98
|
| Rate for Payer: Cash Price |
$98.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$121.79
|
| Rate for Payer: Heritage Provider Network Senior |
$121.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.98
|
| Rate for Payer: Multiplan Commercial |
$134.93
|
|
|
IMATINIB 100 MG TABLET [32979]
|
Facility
|
IP
|
$1.47
|
|
|
Service Code
|
HCPCS S0088
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Adventist Health Commercial |
$0.91
|
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cash Price |
$0.81
|
| 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: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| 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: 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: Multiplan Commercial |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$3.41
|
|
|
IMATINIB 100 MG TABLET [32979]
|
Facility
|
OP
|
$1.97
|
|
|
Service Code
|
HCPCS S0088
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$7.68 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Adventist Health Commercial |
$0.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.68
|
| Rate for Payer: Blue Shield of California Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$2.78
|
| Rate for Payer: Blue Shield of California EPN |
$2.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cash Price |
$1.08
|
| 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 |
$2.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.67
|
| 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: EPIC Health Plan Commercial |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.91
|
| 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 |
$2.82
|
| Rate for Payer: Heritage Provider Network Senior |
$1.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| 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 |
$1.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$3.41
|
| 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 |
$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: United Healthcare All Other HMO/non HMO |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.87
|
| Rate for Payer: Vantage Medical Group Senior |
$1.67
|
| Rate for Payer: Vantage Medical Group Senior |
$3.87
|
| Rate for Payer: Vantage Medical Group Senior |
$1.25
|
|
|
IMATINIB 400 MG TABLET [36092]
|
Facility
|
OP
|
$5.20
|
|
|
Service Code
|
HCPCS S0088
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$7.68 |
| Rate for Payer: Adventist Health Commercial |
$1.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.68
|
| Rate for Payer: Blue Shield of California Commercial |
$3.17
|
| Rate for Payer: Blue Shield of California EPN |
$2.54
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.42
|
| Rate for Payer: Dignity Health Senior |
$4.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.64
|
| Rate for Payer: Multiplan Commercial |
$3.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.08
|
| Rate for Payer: TriValley Medical Group Senior |
$2.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.42
|
| Rate for Payer: Vantage Medical Group Senior |
$4.42
|
|
|
IMATINIB 400 MG TABLET [36092]
|
Facility
|
IP
|
$5.20
|
|
|
Service Code
|
HCPCS S0088
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Adventist Health Commercial |
$1.04
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.52
|
| Rate for Payer: Heritage Provider Network Senior |
$3.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$3.90
|
|
|
IMIPENEM-CILASTATIN 250 MG INTRAVENOUS SOLUTION [9602]
|
Facility
|
OP
|
$20.51
|
|
|
Service Code
|
HCPCS J0743
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$28.27 |
| Rate for Payer: Adventist Health Commercial |
$4.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.27
|
| Rate for Payer: Blue Shield of California Commercial |
$10.92
|
| Rate for Payer: Blue Shield of California EPN |
$10.92
|
| Rate for Payer: Cash Price |
$11.28
|
| Rate for Payer: Cash Price |
$11.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.43
|
| Rate for Payer: Dignity Health Senior |
$17.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.50
|
| Rate for Payer: Heritage Provider Network Senior |
$9.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.36
|
| Rate for Payer: Multiplan Commercial |
$15.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.20
|
| Rate for Payer: TriValley Medical Group Senior |
$8.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.43
|
| Rate for Payer: Vantage Medical Group Senior |
$17.43
|
|
|
IMIPENEM-CILASTATIN 250 MG INTRAVENOUS SOLUTION [9602]
|
Facility
|
IP
|
$20.51
|
|
|
Service Code
|
HCPCS J0743
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$15.38 |
| Rate for Payer: Adventist Health Commercial |
$4.10
|
| Rate for Payer: Cash Price |
$11.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.50
|
| Rate for Payer: Heritage Provider Network Senior |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.13
|
| Rate for Payer: Multiplan Commercial |
$15.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.79
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]
|
Facility
|
OP
|
$35.98
|
|
|
Service Code
|
HCPCS J0743
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$30.58 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Adventist Health Commercial |
$6.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.23
|
| 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 |
$30.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.27
|
| Rate for Payer: Blue Shield of California Commercial |
$10.92
|
| Rate for Payer: Blue Shield of California Commercial |
$10.92
|
| Rate for Payer: Blue Shield of California EPN |
$10.92
|
| Rate for Payer: Blue Shield of California EPN |
$10.92
|
| Rate for Payer: Cash Price |
$19.79
|
| Rate for Payer: Cash Price |
$18.05
|
| Rate for Payer: Cash Price |
$18.05
|
| Rate for Payer: Cash Price |
$19.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.55
|
| 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 |
$27.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.58
|
| Rate for Payer: Dignity Health Senior |
$27.90
|
| Rate for Payer: Dignity Health Senior |
$30.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.00
|
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.66
|
| 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 |
$8.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.19
|
| Rate for Payer: Multiplan Commercial |
$26.98
|
| Rate for Payer: Multiplan Commercial |
$24.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Senior |
$13.13
|
| Rate for Payer: TriValley Medical Group Senior |
$14.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.90
|
| 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
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]
|
Facility
|
IP
|
$32.82
|
|
|
Service Code
|
HCPCS J0743
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$24.61 |
| Rate for Payer: Adventist Health Commercial |
$6.56
|
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Cash Price |
$19.79
|
| Rate for Payer: Cash Price |
$18.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.43
|
| 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 Medi-Cal |
$5.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.21
|
| Rate for Payer: Multiplan Commercial |
$26.98
|
| Rate for Payer: Multiplan Commercial |
$24.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.87
|
|
|
IMIPRAMINE 10 MG TABLET [3860]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 69584-425-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| 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 |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
