|
LECANEMAB-IRMB IN 0.9 % SODIUM CHLORIDE IV INFUSION [40820177]
|
Facility
|
OP
|
$152.88
|
|
|
Service Code
|
NDC 9940-8201-77
|
| Min. Negotiated Rate |
$30.58 |
| Max. Negotiated Rate |
$129.95 |
| Rate for Payer: Adventist Health Commercial |
$30.58
|
| Rate for Payer: Aetna of CA HMO/PPO |
$100.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$129.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$84.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$114.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$93.88
|
| Rate for Payer: Cash Price |
$84.09
|
| Rate for Payer: Cigna of CA HMO |
$97.84
|
| Rate for Payer: Cigna of CA PPO |
$113.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$129.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$129.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$129.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.15
|
| Rate for Payer: EPIC Health Plan Senior |
$61.15
|
| Rate for Payer: Galaxy Health WC |
$129.95
|
| Rate for Payer: Global Benefits Group Commercial |
$91.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$101.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$58.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$94.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$107.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$107.02
|
| Rate for Payer: Multiplan Commercial |
$122.30
|
| Rate for Payer: Networks By Design Commercial |
$99.37
|
| Rate for Payer: Prime Health Services Commercial |
$129.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$91.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$91.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$76.44
|
| Rate for Payer: United Healthcare All Other HMO |
$76.44
|
| Rate for Payer: United Healthcare HMO Rider |
$76.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$76.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$129.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$129.95
|
| Rate for Payer: Vantage Medical Group Senior |
$129.95
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 60505-2502-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.97
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Senior |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.60
|
| Rate for Payer: United Healthcare All Other HMO |
$1.60
|
| Rate for Payer: United Healthcare HMO Rider |
$1.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 70710-1157-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 60505-2502-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.36
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Senior |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 70710-1157-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare HMO Rider |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$3.32
|
|
|
Service Code
|
NDC 60505-2503-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California Commercial |
$2.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.61
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Senior |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.66
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 62332-062-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 62332-062-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare HMO Rider |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 23155-044-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Senior |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.75
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$3.32
|
|
|
Service Code
|
NDC 60505-2503-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.04
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Senior |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.32
|
| Rate for Payer: Multiplan Commercial |
$2.66
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.66
|
| Rate for Payer: United Healthcare All Other HMO |
$1.66
|
| Rate for Payer: United Healthcare HMO Rider |
$1.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Vantage Medical Group Senior |
$2.82
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 23155-044-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Senior |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.75
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
IP
|
$18.97
|
|
|
Service Code
|
NDC 0006-5004-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$16.12 |
| Rate for Payer: Adventist Health Commercial |
$3.79
|
| Rate for Payer: Blue Shield of California Commercial |
$14.00
|
| Rate for Payer: Blue Shield of California EPN |
$9.22
|
| Rate for Payer: Cash Price |
$10.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.59
|
| Rate for Payer: EPIC Health Plan Senior |
$7.59
|
| Rate for Payer: Galaxy Health WC |
$16.12
|
| Rate for Payer: Global Benefits Group Commercial |
$11.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.55
|
| Rate for Payer: Multiplan Commercial |
$15.18
|
| Rate for Payer: Networks By Design Commercial |
$12.33
|
| Rate for Payer: Prime Health Services Commercial |
$16.12
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
OP
|
$18.97
|
|
|
Service Code
|
NDC 0006-5004-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$16.12 |
| Rate for Payer: Adventist Health Commercial |
$3.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$12.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.65
|
| Rate for Payer: Cash Price |
$10.43
|
| Rate for Payer: Cigna of CA HMO |
$12.14
|
| Rate for Payer: Cigna of CA PPO |
$14.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.59
|
| Rate for Payer: EPIC Health Plan Senior |
$7.59
|
| Rate for Payer: Galaxy Health WC |
$16.12
|
| Rate for Payer: Global Benefits Group Commercial |
$11.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.28
|
| Rate for Payer: Multiplan Commercial |
$15.18
|
| Rate for Payer: Networks By Design Commercial |
$12.33
|
| Rate for Payer: Prime Health Services Commercial |
$16.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.48
|
| Rate for Payer: United Healthcare All Other HMO |
$9.48
|
| Rate for Payer: United Healthcare HMO Rider |
$9.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.12
|
| Rate for Payer: Vantage Medical Group Senior |
$16.12
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
IP
|
$18.97
|
|
|
Service Code
|
NDC 0006-5004-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$16.12 |
| Rate for Payer: Adventist Health Commercial |
$3.79
|
| Rate for Payer: Blue Shield of California Commercial |
$14.00
|
| Rate for Payer: Blue Shield of California EPN |
$9.22
|
| Rate for Payer: Cash Price |
$10.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.59
|
| Rate for Payer: EPIC Health Plan Senior |
$7.59
|
| Rate for Payer: Galaxy Health WC |
$16.12
|
| Rate for Payer: Global Benefits Group Commercial |
$11.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.55
|
| Rate for Payer: Multiplan Commercial |
$15.18
|
| Rate for Payer: Networks By Design Commercial |
$12.33
|
| Rate for Payer: Prime Health Services Commercial |
$16.12
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
OP
|
$18.97
|
|
|
Service Code
|
NDC 0006-5004-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$16.12 |
| Rate for Payer: Adventist Health Commercial |
$3.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$12.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.65
|
| Rate for Payer: Cash Price |
$10.43
|
| Rate for Payer: Cigna of CA HMO |
$12.14
|
| Rate for Payer: Cigna of CA PPO |
$14.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.59
|
| Rate for Payer: EPIC Health Plan Senior |
$7.59
|
| Rate for Payer: Galaxy Health WC |
$16.12
|
| Rate for Payer: Global Benefits Group Commercial |
$11.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.28
|
| Rate for Payer: Multiplan Commercial |
$15.18
|
| Rate for Payer: Networks By Design Commercial |
$12.33
|
| Rate for Payer: Prime Health Services Commercial |
$16.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.48
|
| Rate for Payer: United Healthcare All Other HMO |
$9.48
|
| Rate for Payer: United Healthcare HMO Rider |
$9.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.12
|
| Rate for Payer: Vantage Medical Group Senior |
$16.12
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
IP
|
$329.27
|
|
|
Service Code
|
NDC 0006-3076-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$279.88 |
| Rate for Payer: Adventist Health Commercial |
$65.85
|
| Rate for Payer: Blue Shield of California Commercial |
$243.00
|
| Rate for Payer: Blue Shield of California EPN |
$160.03
|
| Rate for Payer: Cash Price |
$181.10
|
| Rate for Payer: Cigna of CA HMO |
$230.49
|
| Rate for Payer: Cigna of CA PPO |
$230.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$131.71
|
| Rate for Payer: EPIC Health Plan Senior |
$131.71
|
| Rate for Payer: Galaxy Health WC |
$279.88
|
| Rate for Payer: Global Benefits Group Commercial |
$197.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$219.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$203.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$79.02
|
| Rate for Payer: Multiplan Commercial |
$263.42
|
| Rate for Payer: Networks By Design Commercial |
$214.03
|
| Rate for Payer: Prime Health Services Commercial |
$279.88
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
IP
|
$329.27
|
|
|
Service Code
|
NDC 0006-3076-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$279.88 |
| Rate for Payer: Adventist Health Commercial |
$65.85
|
| Rate for Payer: Blue Shield of California Commercial |
$243.00
|
| Rate for Payer: Blue Shield of California EPN |
$160.03
|
| Rate for Payer: Cash Price |
$181.10
|
| Rate for Payer: Cigna of CA HMO |
$230.49
|
| Rate for Payer: Cigna of CA PPO |
$230.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$131.71
|
| Rate for Payer: EPIC Health Plan Senior |
$131.71
|
| Rate for Payer: Galaxy Health WC |
$279.88
|
| Rate for Payer: Global Benefits Group Commercial |
$197.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$219.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$203.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$79.02
|
| Rate for Payer: Multiplan Commercial |
$263.42
|
| Rate for Payer: Networks By Design Commercial |
$214.03
|
| Rate for Payer: Prime Health Services Commercial |
$279.88
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
OP
|
$329.27
|
|
|
Service Code
|
NDC 0006-3076-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$279.88 |
| Rate for Payer: Adventist Health Commercial |
$65.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$215.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$279.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$181.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$246.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$202.20
|
| Rate for Payer: Cash Price |
$181.10
|
| Rate for Payer: Cigna of CA HMO |
$230.49
|
| Rate for Payer: Cigna of CA PPO |
$230.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$279.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$279.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$279.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$131.71
|
| Rate for Payer: EPIC Health Plan Senior |
$131.71
|
| Rate for Payer: Galaxy Health WC |
$279.88
|
| Rate for Payer: Global Benefits Group Commercial |
$197.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$219.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$203.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$79.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$230.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$230.49
|
| Rate for Payer: Multiplan Commercial |
$263.42
|
| Rate for Payer: Networks By Design Commercial |
$214.03
|
| Rate for Payer: Prime Health Services Commercial |
$279.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$197.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$197.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$164.63
|
| Rate for Payer: United Healthcare All Other HMO |
$164.63
|
| Rate for Payer: United Healthcare HMO Rider |
$164.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$164.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$279.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$279.88
|
| Rate for Payer: Vantage Medical Group Senior |
$279.88
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
OP
|
$329.27
|
|
|
Service Code
|
NDC 0006-3076-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$279.88 |
| Rate for Payer: Adventist Health Commercial |
$65.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$215.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$279.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$181.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$246.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$202.20
|
| Rate for Payer: Cash Price |
$181.10
|
| Rate for Payer: Cigna of CA HMO |
$230.49
|
| Rate for Payer: Cigna of CA PPO |
$230.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$279.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$279.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$279.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$131.71
|
| Rate for Payer: EPIC Health Plan Senior |
$131.71
|
| Rate for Payer: Galaxy Health WC |
$279.88
|
| Rate for Payer: Global Benefits Group Commercial |
$197.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$219.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$203.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$79.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$230.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$230.49
|
| Rate for Payer: Multiplan Commercial |
$263.42
|
| Rate for Payer: Networks By Design Commercial |
$214.03
|
| Rate for Payer: Prime Health Services Commercial |
$279.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$197.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$197.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$164.63
|
| Rate for Payer: United Healthcare All Other HMO |
$164.63
|
| Rate for Payer: United Healthcare HMO Rider |
$164.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$164.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$279.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$279.88
|
| Rate for Payer: Vantage Medical Group Senior |
$279.88
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 16729-034-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 16729-034-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
