|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
IP
|
$434.29
|
|
|
Service Code
|
NDC 69344-102-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$78.61 |
| Max. Negotiated Rate |
$325.72 |
| Rate for Payer: Adventist Health Commercial |
$86.86
|
| Rate for Payer: Cash Price |
$238.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$234.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$294.01
|
| Rate for Payer: Heritage Provider Network Senior |
$294.01
|
| 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: Multiplan Commercial |
$325.72
|
|
|
INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 68462-325-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 68462-325-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| 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 |
$0.20
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Senior |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| 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 Commercial |
$0.20
|
| 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 |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.29
|
| 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 |
$0.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]
|
Facility
|
IP
|
$570.00
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.17 |
| Max. Negotiated Rate |
$427.50 |
| Rate for Payer: Adventist Health Commercial |
$114.00
|
| Rate for Payer: Cash Price |
$313.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$262.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$307.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$263.91
|
| Rate for Payer: Heritage Provider Network Senior |
$263.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$103.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$142.50
|
| Rate for Payer: Multiplan Commercial |
$427.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$205.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$188.73
|
|
|
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]
|
Facility
|
OP
|
$570.00
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.52 |
| Max. Negotiated Rate |
$427.50 |
| Rate for Payer: Adventist Health Commercial |
$114.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$304.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$391.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$34.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$123.02
|
| Rate for Payer: Blue Shield of California Commercial |
$48.45
|
| Rate for Payer: Blue Shield of California EPN |
$48.45
|
| Rate for Payer: Cash Price |
$313.50
|
| Rate for Payer: Cash Price |
$313.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$262.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.30
|
| Rate for Payer: Dignity Health Senior |
$34.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$364.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$31.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$263.91
|
| Rate for Payer: Heritage Provider Network Senior |
$263.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$31.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$271.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$103.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$142.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.29
|
| Rate for Payer: Multiplan Commercial |
$427.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$228.00
|
| Rate for Payer: TriValley Medical Group Senior |
$228.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$205.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$188.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.30
|
| Rate for Payer: Vantage Medical Group Senior |
$34.30
|
|
|
INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]
|
Facility
|
OP
|
$904.07
|
|
|
Service Code
|
HCPCS Q5104
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$678.05 |
| Rate for Payer: Adventist Health Commercial |
$180.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$483.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$621.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$37.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$195.13
|
| Rate for Payer: Blue Shield of California Commercial |
$76.85
|
| Rate for Payer: Blue Shield of California EPN |
$76.85
|
| Rate for Payer: Cash Price |
$497.24
|
| Rate for Payer: Cash Price |
$497.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$415.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.56
|
| Rate for Payer: Dignity Health Senior |
$27.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$578.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$25.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$418.58
|
| Rate for Payer: Heritage Provider Network Senior |
$418.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$25.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$431.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$163.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$226.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$31.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$31.57
|
| Rate for Payer: Multiplan Commercial |
$678.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$361.63
|
| Rate for Payer: TriValley Medical Group Senior |
$361.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$326.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$299.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.56
|
| Rate for Payer: Vantage Medical Group Senior |
$27.56
|
|
|
INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]
|
Facility
|
IP
|
$904.07
|
|
|
Service Code
|
HCPCS Q5104
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$163.64 |
| Max. Negotiated Rate |
$678.05 |
| Rate for Payer: Adventist Health Commercial |
$180.81
|
| Rate for Payer: Cash Price |
$497.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$415.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$488.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$418.58
|
| Rate for Payer: Heritage Provider Network Senior |
$418.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$163.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$226.02
|
| Rate for Payer: Multiplan Commercial |
$678.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$326.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$299.34
|
|
|
INJ CHEST TUBE W/FIBRINOLYTIC INITIAL DAY
|
Facility
|
OP
|
$2,847.00
|
|
|
Service Code
|
CPT 32561
|
| Hospital Charge Code |
909020046
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$569.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,955.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,178.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$864.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$785.56
|
| 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 |
$1,565.85
|
| Rate for Payer: Cash Price |
$1,565.85
|
| Rate for Payer: Cash Price |
$1,565.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,850.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,178.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$864.12
|
| Rate for Payer: Dignity Health Senior |
$785.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$785.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,762.29
|
| Rate for Payer: Heritage Provider Network Senior |
$966.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$129.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$785.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,492.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$515.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$903.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$711.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$989.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$989.81
|
| Rate for Payer: Multiplan Commercial |
$2,135.25
|
| Rate for Payer: Multiplan WC |
$1,251.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$864.12
|
| Rate for Payer: TriValley Medical Group Senior |
$864.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,731.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,298.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,178.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$864.12
|
| Rate for Payer: Vantage Medical Group Senior |
$785.56
|
|
|
INJ CHEST TUBE W/FIBRINOLYTIC INITIAL DAY
|
Facility
|
IP
|
$2,847.00
|
|
|
Service Code
|
CPT 32561
|
| Hospital Charge Code |
909020046
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$515.31 |
| Max. Negotiated Rate |
$2,135.25 |
| Rate for Payer: Adventist Health Commercial |
$569.40
|
| Rate for Payer: Cash Price |
$1,565.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,927.42
|
| Rate for Payer: Heritage Provider Network Senior |
$1,927.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$515.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$711.75
|
| Rate for Payer: Multiplan Commercial |
$2,135.25
|
|
|
INJ CHEST TUBE W/FIBRINOLYTIC SUB DAY
|
Facility
|
OP
|
$2,998.00
|
|
|
Service Code
|
CPT 32562
|
| Hospital Charge Code |
909020047
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$599.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,059.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,178.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$864.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$785.56
|
| 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 |
$1,648.90
|
| Rate for Payer: Cash Price |
$1,648.90
|
| Rate for Payer: Cash Price |
$1,648.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,948.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,178.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$864.12
|
| Rate for Payer: Dignity Health Senior |
$785.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$785.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,855.76
|
| Rate for Payer: Heritage Provider Network Senior |
$966.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$785.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,492.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$542.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$903.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$749.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$989.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$989.81
|
| Rate for Payer: Multiplan Commercial |
$2,248.50
|
| Rate for Payer: Multiplan WC |
$1,251.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$864.12
|
| Rate for Payer: TriValley Medical Group Senior |
$864.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,731.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,298.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,178.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$864.12
|
| Rate for Payer: Vantage Medical Group Senior |
$785.56
|
|
|
INJ CHEST TUBE W/FIBRINOLYTIC SUB DAY
|
Facility
|
IP
|
$2,998.00
|
|
|
Service Code
|
CPT 32562
|
| Hospital Charge Code |
909020047
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$542.64 |
| Max. Negotiated Rate |
$2,248.50 |
| Rate for Payer: Adventist Health Commercial |
$599.60
|
| Rate for Payer: Cash Price |
$1,648.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,029.65
|
| Rate for Payer: Heritage Provider Network Senior |
$2,029.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$542.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$749.50
|
| Rate for Payer: Multiplan Commercial |
$2,248.50
|
|
|
INSULIN ASPAR PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS SOLN [114723]
|
Facility
|
IP
|
$8.68
|
|
|
Service Code
|
NDC 0169-3685-12
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$6.51 |
| Rate for Payer: Adventist Health Commercial |
$1.74
|
| Rate for Payer: Cash Price |
$4.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.88
|
| Rate for Payer: Heritage Provider Network Senior |
$5.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.17
|
| Rate for Payer: Multiplan Commercial |
$6.51
|
|
|
INSULIN ASPAR PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS SOLN [114723]
|
Facility
|
OP
|
$8.68
|
|
|
Service Code
|
NDC 0169-3685-12
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$7.38 |
| Rate for Payer: Adventist Health Commercial |
$1.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.51
|
| Rate for Payer: Blue Shield of California Commercial |
$5.29
|
| Rate for Payer: Blue Shield of California EPN |
$4.24
|
| Rate for Payer: Cash Price |
$4.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.38
|
| Rate for Payer: Dignity Health Senior |
$7.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.37
|
| Rate for Payer: Heritage Provider Network Senior |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.08
|
| Rate for Payer: Multiplan Commercial |
$6.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.38
|
| Rate for Payer: Vantage Medical Group Senior |
$7.38
|
|
|
INSULIN ASPART U-100 100 UNIT/ML SUBCUTANEOUS SOLUTION [28534]
|
Facility
|
IP
|
$8.68
|
|
|
Service Code
|
NDC 0169-7501-11
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$6.51 |
| Rate for Payer: Adventist Health Commercial |
$1.74
|
| Rate for Payer: Cash Price |
$4.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.88
|
| Rate for Payer: Heritage Provider Network Senior |
$5.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.17
|
| Rate for Payer: Multiplan Commercial |
$6.51
|
|
|
INSULIN ASPART U-100 100 UNIT/ML SUBCUTANEOUS SOLUTION [28534]
|
Facility
|
OP
|
$8.68
|
|
|
Service Code
|
NDC 0169-7501-11
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$7.38 |
| Rate for Payer: Adventist Health Commercial |
$1.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.51
|
| Rate for Payer: Blue Shield of California Commercial |
$5.29
|
| Rate for Payer: Blue Shield of California EPN |
$4.24
|
| Rate for Payer: Cash Price |
$4.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.38
|
| Rate for Payer: Dignity Health Senior |
$7.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.37
|
| Rate for Payer: Heritage Provider Network Senior |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.08
|
| Rate for Payer: Multiplan Commercial |
$6.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.38
|
| Rate for Payer: Vantage Medical Group Senior |
$7.38
|
|
|
INSULIN DEGLUDEC (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [223708]
|
Facility
|
OP
|
$40.67
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$34.57 |
| Rate for Payer: Adventist Health Commercial |
$8.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$21.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$34.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$30.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.58
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$22.37
|
| Rate for Payer: Cash Price |
$22.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$34.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.57
|
| Rate for Payer: Dignity Health Senior |
$34.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.83
|
| Rate for Payer: Heritage Provider Network Senior |
$18.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$19.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$28.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$28.47
|
| Rate for Payer: Multiplan Commercial |
$30.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.27
|
| Rate for Payer: TriValley Medical Group Senior |
$16.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$34.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.57
|
| Rate for Payer: Vantage Medical Group Senior |
$34.57
|
|
|
INSULIN DEGLUDEC (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [223708]
|
Facility
|
IP
|
$40.67
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$30.50 |
| Rate for Payer: Adventist Health Commercial |
$8.13
|
| Rate for Payer: Cash Price |
$22.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.83
|
| Rate for Payer: Heritage Provider Network Senior |
$18.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.17
|
| Rate for Payer: Multiplan Commercial |
$30.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.47
|
|
|
INSULIN GLARGINE VIAL (LANTUS) 100 UNIT/ML SUBCUTANEOUS [28282]
|
Facility
|
OP
|
$7.71
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$7.86 |
| Rate for Payer: Adventist Health Commercial |
$1.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.58
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.55
|
| Rate for Payer: Dignity Health Senior |
$6.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.57
|
| Rate for Payer: Heritage Provider Network Senior |
$3.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$5.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.08
|
| Rate for Payer: TriValley Medical Group Senior |
$3.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.55
|
| Rate for Payer: Vantage Medical Group Senior |
$6.55
|
|
|
INSULIN GLARGINE VIAL (LANTUS) 100 UNIT/ML SUBCUTANEOUS [28282]
|
Facility
|
IP
|
$7.71
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$5.78 |
| Rate for Payer: Adventist Health Commercial |
$1.54
|
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.57
|
| Rate for Payer: Heritage Provider Network Senior |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.93
|
| Rate for Payer: Multiplan Commercial |
$5.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.55
|
|
|
INSULIN GLULISINE (APIDRA) 100 UNIT/ML BOLUS FROM PUMP [4081881]
|
Facility
|
OP
|
$10.22
|
|
|
Service Code
|
NDC 0088-2500-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$8.69 |
| Rate for Payer: Adventist Health Commercial |
$2.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.67
|
| Rate for Payer: Blue Shield of California Commercial |
$6.23
|
| Rate for Payer: Blue Shield of California EPN |
$4.99
|
| Rate for Payer: Cash Price |
$5.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.69
|
| Rate for Payer: Dignity Health Senior |
$8.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.33
|
| Rate for Payer: Heritage Provider Network Senior |
$6.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.15
|
| Rate for Payer: Multiplan Commercial |
$7.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.09
|
| Rate for Payer: TriValley Medical Group Senior |
$4.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.69
|
| Rate for Payer: Vantage Medical Group Senior |
$8.69
|
|
|
INSULIN GLULISINE (APIDRA) 100 UNIT/ML BOLUS FROM PUMP [4081881]
|
Facility
|
IP
|
$10.22
|
|
|
Service Code
|
NDC 0088-2500-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$7.67 |
| Rate for Payer: Adventist Health Commercial |
$2.04
|
| Rate for Payer: Cash Price |
$5.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.92
|
| Rate for Payer: Heritage Provider Network Senior |
$6.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.56
|
| Rate for Payer: Multiplan Commercial |
$7.67
|
|
|
INSULIN GLULISINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [87889]
|
Facility
|
OP
|
$26.79
|
|
|
Service Code
|
NDC 0088-2500-34
|
| Min. Negotiated Rate |
$4.85 |
| Max. Negotiated Rate |
$22.77 |
| Rate for Payer: Adventist Health Commercial |
$5.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.09
|
| Rate for Payer: Blue Shield of California Commercial |
$16.34
|
| Rate for Payer: Blue Shield of California EPN |
$13.07
|
| Rate for Payer: Cash Price |
$14.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.77
|
| Rate for Payer: Dignity Health Senior |
$22.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.58
|
| Rate for Payer: Heritage Provider Network Senior |
$16.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.75
|
| Rate for Payer: Multiplan Commercial |
$20.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.77
|
| Rate for Payer: Vantage Medical Group Senior |
$22.77
|
|
|
INSULIN GLULISINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [87889]
|
Facility
|
IP
|
$26.79
|
|
|
Service Code
|
NDC 0088-2500-34
|
| Min. Negotiated Rate |
$4.85 |
| Max. Negotiated Rate |
$20.09 |
| Rate for Payer: Adventist Health Commercial |
$5.36
|
| Rate for Payer: Cash Price |
$14.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.14
|
| Rate for Payer: Heritage Provider Network Senior |
$18.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$20.09
|
|
|
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP [10286]
|
Facility
|
IP
|
$5.35
|
|
|
Service Code
|
HCPCS J1815
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$4.01 |
| Rate for Payer: Adventist Health Commercial |
$1.07
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.62
|
| Rate for Payer: Heritage Provider Network Senior |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$4.01
|
|
|
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP [10286]
|
Facility
|
OP
|
$5.35
|
|
|
Service Code
|
HCPCS J1815
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$7.86 |
| Rate for Payer: Adventist Health Commercial |
$1.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.58
|
| Rate for Payer: Blue Shield of California Commercial |
$3.26
|
| Rate for Payer: Blue Shield of California EPN |
$2.61
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.55
|
| Rate for Payer: Dignity Health Senior |
$4.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.31
|
| Rate for Payer: Heritage Provider Network Senior |
$3.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$4.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.55
|
| Rate for Payer: Vantage Medical Group Senior |
$4.55
|
|
