|
DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN [228045]
|
Facility
|
OP
|
$845.75
|
|
|
Service Code
|
HCPCS J9144
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$465.16 |
| Max. Negotiated Rate |
$676.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$507.45
|
| Rate for Payer: Aetna of CA Government/Medicare |
$507.45
|
| Rate for Payer: Cash Price |
$465.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$676.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$507.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$507.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$465.16
|
| Rate for Payer: Multiplan Commercial |
$634.31
|
|
|
DARATUMUMAB-HYALURONIDASE-FIHJ (DARZALEX FASPRO) 1800 MG/30000 UNIT SQ INJECTION [40820601]
|
Facility
|
IP
|
$845.75
|
|
|
Service Code
|
HCPCS J9144
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$465.16 |
| Max. Negotiated Rate |
$676.60 |
| Rate for Payer: Cash Price |
$465.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$676.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$507.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$465.16
|
| Rate for Payer: Multiplan Commercial |
$634.31
|
|
|
DARATUMUMAB-HYALURONIDASE-FIHJ (DARZALEX FASPRO) 1800 MG/30000 UNIT SQ INJECTION [40820601]
|
Facility
|
OP
|
$845.75
|
|
|
Service Code
|
HCPCS J9144
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$465.16 |
| Max. Negotiated Rate |
$676.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$507.45
|
| Rate for Payer: Aetna of CA Government/Medicare |
$507.45
|
| Rate for Payer: Cash Price |
$465.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$676.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$507.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$507.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$465.16
|
| Rate for Payer: Multiplan Commercial |
$634.31
|
|
|
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE [108041]
|
Facility
|
IP
|
$552.86
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$304.07 |
| Max. Negotiated Rate |
$442.29 |
| Rate for Payer: Cash Price |
$304.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$442.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$331.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$304.07
|
| Rate for Payer: Multiplan Commercial |
$414.64
|
|
|
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE [108041]
|
Facility
|
OP
|
$552.86
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$304.07 |
| Max. Negotiated Rate |
$442.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$331.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$331.72
|
| Rate for Payer: Cash Price |
$304.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$442.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$331.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$331.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$304.07
|
| Rate for Payer: Multiplan Commercial |
$414.64
|
|
|
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [108042]
|
Facility
|
OP
|
$928.80
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$510.84 |
| Max. Negotiated Rate |
$743.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$557.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$557.28
|
| Rate for Payer: Cash Price |
$510.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$743.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$557.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$557.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$510.84
|
| Rate for Payer: Multiplan Commercial |
$696.60
|
|
|
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [108042]
|
Facility
|
IP
|
$928.80
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$510.84 |
| Max. Negotiated Rate |
$743.04 |
| Rate for Payer: Cash Price |
$510.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$743.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$557.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$510.84
|
| Rate for Payer: Multiplan Commercial |
$696.60
|
|
|
DAROLUTAMIDE 300 MG TABLET [225419]
|
Facility
|
IP
|
$142.54
|
|
|
Service Code
|
NDC 50419-395-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$114.03 |
| Rate for Payer: Cash Price |
$78.39
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$114.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$85.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.40
|
| Rate for Payer: Multiplan Commercial |
$106.91
|
|
|
DAROLUTAMIDE 300 MG TABLET [225419]
|
Facility
|
OP
|
$142.54
|
|
|
Service Code
|
NDC 50419-395-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$114.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$85.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$85.52
|
| Rate for Payer: Cash Price |
$78.39
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$114.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$85.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$85.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.40
|
| Rate for Payer: Multiplan Commercial |
$106.91
|
|
|
DARUNAVIR 600 MG TABLET [92851]
|
Facility
|
IP
|
$43.16
|
|
|
Service Code
|
NDC 59676-562-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.74 |
| Max. Negotiated Rate |
$34.53 |
| Rate for Payer: Cash Price |
$23.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$34.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$25.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.74
|
| Rate for Payer: Multiplan Commercial |
$32.37
|
|
|
DARUNAVIR 600 MG TABLET [92851]
|
Facility
|
OP
|
$43.16
|
|
|
Service Code
|
NDC 59676-562-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.74 |
| Max. Negotiated Rate |
$34.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$25.90
|
| Rate for Payer: Aetna of CA Government/Medicare |
$25.90
|
| Rate for Payer: Cash Price |
$23.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$34.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$25.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$25.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.74
|
| Rate for Payer: Multiplan Commercial |
$32.37
|
|
|
DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET [208697]
|
Facility
|
IP
|
$98.67
|
|
|
Service Code
|
NDC 59676-575-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$54.27 |
| Max. Negotiated Rate |
$78.94 |
| Rate for Payer: Cash Price |
$54.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$78.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$59.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.27
|
| Rate for Payer: Multiplan Commercial |
$74.00
|
|
|
DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET [208697]
|
Facility
|
OP
|
$98.67
|
|
|
Service Code
|
NDC 59676-575-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$54.27 |
| Max. Negotiated Rate |
$78.94 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$59.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$59.20
|
| Rate for Payer: Cash Price |
$54.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$78.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$59.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$59.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.27
|
| Rate for Payer: Multiplan Commercial |
$74.00
|
|
|
DARUNAVIR 800 MG TABLET [199468]
|
Facility
|
OP
|
$12.30
|
|
|
Service Code
|
NDC 60687-819-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$9.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.38
|
| Rate for Payer: Cash Price |
$6.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.76
|
| Rate for Payer: Multiplan Commercial |
$9.22
|
|
|
DARUNAVIR 800 MG TABLET [199468]
|
Facility
|
IP
|
$12.30
|
|
|
Service Code
|
NDC 60687-819-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$9.84 |
| Rate for Payer: Cash Price |
$6.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.76
|
| Rate for Payer: Multiplan Commercial |
$9.22
|
|
|
DARUNAVIR 800 MG TABLET [199468]
|
Facility
|
OP
|
$86.33
|
|
|
Service Code
|
NDC 59676-566-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$47.48 |
| Max. Negotiated Rate |
$69.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$51.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$51.80
|
| Rate for Payer: Cash Price |
$47.48
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$69.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$51.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$51.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.48
|
| Rate for Payer: Multiplan Commercial |
$64.75
|
|
|
DARUNAVIR 800 MG TABLET [199468]
|
Facility
|
IP
|
$86.33
|
|
|
Service Code
|
NDC 59676-566-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$47.48 |
| Max. Negotiated Rate |
$69.06 |
| Rate for Payer: Cash Price |
$47.48
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$69.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$51.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.48
|
| Rate for Payer: Multiplan Commercial |
$64.75
|
|
|
DARUNAVIR 800 MG TABLET [199468]
|
Facility
|
IP
|
$12.30
|
|
|
Service Code
|
NDC 60687-819-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$9.84 |
| Rate for Payer: Cash Price |
$6.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.76
|
| Rate for Payer: Multiplan Commercial |
$9.22
|
|
|
DARUNAVIR 800 MG TABLET [199468]
|
Facility
|
IP
|
$3.96
|
|
|
Service Code
|
NDC 68180-346-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$2.97
|
|
|
DARUNAVIR 800 MG TABLET [199468]
|
Facility
|
OP
|
$12.30
|
|
|
Service Code
|
NDC 60687-819-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$9.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.38
|
| Rate for Payer: Cash Price |
$6.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.76
|
| Rate for Payer: Multiplan Commercial |
$9.22
|
|
|
DARUNAVIR 800 MG TABLET [199468]
|
Facility
|
OP
|
$3.96
|
|
|
Service Code
|
NDC 68180-346-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.38
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$2.97
|
|
|
DASATINIB 100 MG TABLET [92897]
|
Facility
|
IP
|
$729.85
|
|
|
Service Code
|
NDC 0003-0852-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$401.42 |
| Max. Negotiated Rate |
$583.88 |
| Rate for Payer: Cash Price |
$401.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$583.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$437.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$401.42
|
| Rate for Payer: Multiplan Commercial |
$547.39
|
|
|
DASATINIB 100 MG TABLET [92897]
|
Facility
|
OP
|
$729.85
|
|
|
Service Code
|
NDC 0003-0852-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$401.42 |
| Max. Negotiated Rate |
$583.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$437.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$437.91
|
| Rate for Payer: Cash Price |
$401.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$583.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$437.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$437.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$401.42
|
| Rate for Payer: Multiplan Commercial |
$547.39
|
|
|
DASATINIB 140 MG TABLET [108422]
|
Facility
|
OP
|
$729.85
|
|
|
Service Code
|
NDC 0003-0857-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$401.42 |
| Max. Negotiated Rate |
$583.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$437.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$437.91
|
| Rate for Payer: Cash Price |
$401.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$583.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$437.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$437.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$401.42
|
| Rate for Payer: Multiplan Commercial |
$547.39
|
|
|
DASATINIB 140 MG TABLET [108422]
|
Facility
|
IP
|
$729.85
|
|
|
Service Code
|
NDC 0003-0857-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$401.42 |
| Max. Negotiated Rate |
$583.88 |
| Rate for Payer: Cash Price |
$401.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$583.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$437.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$401.42
|
| Rate for Payer: Multiplan Commercial |
$547.39
|
|
