|
IMMUNE GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]
|
Facility
|
OP
|
$17.85
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$189.07 |
| Rate for Payer: Adventist Health Commercial |
$3.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$60.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$52.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$189.07
|
| Rate for Payer: Blue Shield of California Commercial |
$72.29
|
| Rate for Payer: Blue Shield of California EPN |
$72.29
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$60.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$52.83
|
| Rate for Payer: Dignity Health Senior |
$52.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.42
|
| Rate for Payer: EPIC Health Plan Medicare |
$48.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.26
|
| Rate for Payer: Heritage Provider Network Senior |
$8.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$55.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$60.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$60.52
|
| Rate for Payer: Multiplan Commercial |
$13.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.14
|
| Rate for Payer: TriValley Medical Group Senior |
$7.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$60.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$52.83
|
| Rate for Payer: Vantage Medical Group Senior |
$52.83
|
|
|
IMMUNE GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]
|
Facility
|
IP
|
$17.85
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$13.39 |
| Rate for Payer: Adventist Health Commercial |
$3.57
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.26
|
| Rate for Payer: Heritage Provider Network Senior |
$8.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.46
|
| Rate for Payer: Multiplan Commercial |
$13.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.91
|
|
|
INC & DRNG,LEG/ANKL;DA OR HTMA
|
Facility
|
OP
|
$7,184.00
|
|
|
Service Code
|
CPT 27603
|
| Hospital Charge Code |
909007603
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,436.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,935.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,454.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,000.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,636.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$3,951.20
|
| Rate for Payer: Cash Price |
$3,951.20
|
| Rate for Payer: Cash Price |
$3,951.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,669.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,454.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,000.17
|
| Rate for Payer: Dignity Health Senior |
$3,636.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,636.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,446.90
|
| Rate for Payer: Heritage Provider Network Senior |
$4,472.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$194.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,636.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6,909.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,300.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,182.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,796.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,582.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,582.02
|
| Rate for Payer: Multiplan Commercial |
$5,388.00
|
| Rate for Payer: Multiplan WC |
$5,794.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,000.17
|
| Rate for Payer: TriValley Medical Group Senior |
$4,000.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,454.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,000.17
|
| Rate for Payer: Vantage Medical Group Senior |
$3,636.52
|
|
|
INC & DRNG,LEG/ANKL;DA OR HTMA
|
Facility
|
IP
|
$7,184.00
|
|
|
Service Code
|
CPT 27603
|
| Hospital Charge Code |
909007603
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,300.30 |
| Max. Negotiated Rate |
$5,388.00 |
| Rate for Payer: Adventist Health Commercial |
$1,436.80
|
| Rate for Payer: Cash Price |
$3,951.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,863.57
|
| Rate for Payer: Heritage Provider Network Senior |
$4,863.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,300.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,796.00
|
| Rate for Payer: Multiplan Commercial |
$5,388.00
|
|
|
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]
|
Facility
|
OP
|
$613.20
|
|
|
Service Code
|
HCPCS J0588
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.30 |
| Max. Negotiated Rate |
$459.90 |
| Rate for Payer: Adventist Health Commercial |
$122.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$327.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$421.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.45
|
| Rate for Payer: Blue Shield of California Commercial |
$5.30
|
| Rate for Payer: Blue Shield of California EPN |
$5.30
|
| Rate for Payer: Cash Price |
$337.26
|
| Rate for Payer: Cash Price |
$337.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$282.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.84
|
| Rate for Payer: Dignity Health Senior |
$5.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$392.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$283.91
|
| Rate for Payer: Heritage Provider Network Senior |
$283.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$292.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$110.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$153.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.69
|
| Rate for Payer: Multiplan Commercial |
$459.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$245.28
|
| Rate for Payer: TriValley Medical Group Senior |
$245.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$221.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$203.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.84
|
| Rate for Payer: Vantage Medical Group Senior |
$5.84
|
|
|
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]
|
Facility
|
IP
|
$613.20
|
|
|
Service Code
|
HCPCS J0588
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.99 |
| Max. Negotiated Rate |
$459.90 |
| Rate for Payer: Adventist Health Commercial |
$122.64
|
| Rate for Payer: Cash Price |
$337.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$282.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$331.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$283.91
|
| Rate for Payer: Heritage Provider Network Senior |
$283.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$110.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$153.30
|
| Rate for Payer: Multiplan Commercial |
$459.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$221.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$203.03
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$51.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.90
|
| Rate for Payer: Blue Shield of California Commercial |
$58.56
|
| Rate for Payer: Blue Shield of California EPN |
$46.85
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.95
|
| Rate for Payer: Dignity Health Senior |
$9.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.44
|
| Rate for Payer: EPIC Health Plan Medicare |
$9.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.45
|
| Rate for Payer: Heritage Provider Network Senior |
$44.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$45.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.54
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$38.40
|
| Rate for Payer: TriValley Medical Group Senior |
$38.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.95
|
| Rate for Payer: Vantage Medical Group Senior |
$9.96
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.38 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.45
|
| Rate for Payer: Heritage Provider Network Senior |
$44.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.00
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.79
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$343.00
|
|
|
Service Code
|
NDC 70100-825-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.08 |
| Max. Negotiated Rate |
$257.25 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$185.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$232.21
|
| Rate for Payer: Heritage Provider Network Senior |
$232.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$62.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.75
|
| Rate for Payer: Multiplan Commercial |
$257.25
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$343.00
|
|
|
Service Code
|
NDC 70100-725-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.08 |
| Max. Negotiated Rate |
$257.25 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$185.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$232.21
|
| Rate for Payer: Heritage Provider Network Senior |
$232.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$62.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.75
|
| Rate for Payer: Multiplan Commercial |
$257.25
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
OP
|
$343.00
|
|
|
Service Code
|
NDC 70100-825-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.08 |
| Max. Negotiated Rate |
$291.55 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$183.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$235.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$257.25
|
| Rate for Payer: Blue Shield of California Commercial |
$209.23
|
| Rate for Payer: Blue Shield of California EPN |
$167.38
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$222.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$291.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$291.55
|
| Rate for Payer: Dignity Health Senior |
$291.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$212.32
|
| Rate for Payer: Heritage Provider Network Senior |
$212.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$163.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$62.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$240.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$240.10
|
| Rate for Payer: Multiplan Commercial |
$257.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$137.20
|
| Rate for Payer: TriValley Medical Group Senior |
$137.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$171.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$171.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$291.55
|
| Rate for Payer: Vantage Medical Group Senior |
$291.55
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
OP
|
$343.00
|
|
|
Service Code
|
NDC 70100-725-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.08 |
| Max. Negotiated Rate |
$291.55 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$183.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$235.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$257.25
|
| Rate for Payer: Blue Shield of California Commercial |
$209.23
|
| Rate for Payer: Blue Shield of California EPN |
$167.38
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$222.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$291.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$291.55
|
| Rate for Payer: Dignity Health Senior |
$291.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$212.32
|
| Rate for Payer: Heritage Provider Network Senior |
$212.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$163.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$62.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$240.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$240.10
|
| Rate for Payer: Multiplan Commercial |
$257.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$137.20
|
| Rate for Payer: TriValley Medical Group Senior |
$137.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$171.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$171.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$291.55
|
| Rate for Payer: Vantage Medical Group Senior |
$291.55
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
|
IP
|
$445.49
|
|
|
Service Code
|
NDC 63323-659-94
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.63 |
| Max. Negotiated Rate |
$334.12 |
| Rate for Payer: Adventist Health Commercial |
$89.10
|
| Rate for Payer: Cash Price |
$245.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$240.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$301.60
|
| Rate for Payer: Heritage Provider Network Senior |
$301.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.37
|
| Rate for Payer: Multiplan Commercial |
$334.12
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
|
OP
|
$445.49
|
|
|
Service Code
|
NDC 63323-659-94
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.63 |
| Max. Negotiated Rate |
$378.67 |
| Rate for Payer: Adventist Health Commercial |
$89.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$238.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$306.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$245.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$334.12
|
| Rate for Payer: Blue Shield of California Commercial |
$271.75
|
| Rate for Payer: Blue Shield of California EPN |
$217.40
|
| Rate for Payer: Cash Price |
$245.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$289.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$378.67
|
| Rate for Payer: Dignity Health Senior |
$378.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$285.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$275.76
|
| Rate for Payer: Heritage Provider Network Senior |
$275.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$212.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$311.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$311.84
|
| Rate for Payer: Multiplan Commercial |
$334.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$178.20
|
| Rate for Payer: TriValley Medical Group Senior |
$178.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$222.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$222.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$378.67
|
| Rate for Payer: Vantage Medical Group Senior |
$378.67
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 68462-406-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 68462-406-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 50268-431-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.33
|
| Rate for Payer: Dignity Health Senior |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Vantage Medical Group Senior |
$0.33
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 68462-302-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Senior |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| 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 Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 68462-302-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 50268-431-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
OP
|
$434.29
|
|
|
Service Code
|
NDC 69344-102-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$78.61 |
| Max. Negotiated Rate |
$369.15 |
| Rate for Payer: Adventist Health Commercial |
$86.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$232.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$298.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$369.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$238.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$325.72
|
| Rate for Payer: Blue Shield of California Commercial |
$264.92
|
| Rate for Payer: Blue Shield of California EPN |
$211.93
|
| Rate for Payer: Cash Price |
$238.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$282.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$369.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$369.15
|
| Rate for Payer: Dignity Health Senior |
$369.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$277.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$268.83
|
| Rate for Payer: Heritage Provider Network Senior |
$268.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$207.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$304.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$304.00
|
| Rate for Payer: Multiplan Commercial |
$325.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$173.72
|
| Rate for Payer: TriValley Medical Group Senior |
$173.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$217.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$217.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$369.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$369.15
|
| Rate for Payer: Vantage Medical Group Senior |
$369.15
|
|
