|
LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; WITH DILATION, SUBSEQUENT
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 31529
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$312.73 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,192.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,274.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,795.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,716.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,574.78
|
| Rate for Payer: Blue Shield of California Commercial |
$3,897.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,192.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,274.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,795.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,912.21
|
| Rate for Payer: EPIC Health Plan Senior |
$5,274.81
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,864.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$312.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,795.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$353.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6,713.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,042.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,425.68
|
| Rate for Payer: Multiplan WC |
$7,464.14
|
| Rate for Payer: Prime Health Services WC |
$7,387.98
|
| Rate for Payer: United Healthcare All Other HMO |
$16,122.00
|
| Rate for Payer: United Healthcare HMO Rider |
$10,165.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9,312.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,795.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,192.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,274.81
|
| Rate for Payer: Vantage Medical Group Senior |
$4,795.28
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 2502100102
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$1.83
|
| Rate for Payer: Blue Shield of California Commercial |
$2.77
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Senior |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
| Rate for Payer: Networks By Design Commercial |
$2.34
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
NDC 7006942101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$1.83
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: EPIC Health Plan Senior |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.02
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.02
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 2502100102
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.31
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Senior |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.52
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
| Rate for Payer: Networks By Design Commercial |
$2.34
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO |
$1.80
|
| Rate for Payer: United Healthcare HMO Rider |
$1.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 5976203332
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
OP
|
$5.14
|
|
|
Service Code
|
NDC 6131454701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.30
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO |
$3.60
|
| Rate for Payer: Cigna of CA PPO |
$3.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.06
|
| Rate for Payer: EPIC Health Plan Senior |
$2.06
|
| Rate for Payer: Galaxy Health WC |
$4.37
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$4.11
|
| Rate for Payer: Networks By Design Commercial |
$3.34
|
| Rate for Payer: Prime Health Services Commercial |
$4.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.57
|
| Rate for Payer: United Healthcare All Other HMO |
$2.57
|
| Rate for Payer: United Healthcare HMO Rider |
$2.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.37
|
| Rate for Payer: Vantage Medical Group Senior |
$4.37
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 5976203332
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.77
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
IP
|
$5.14
|
|
|
Service Code
|
NDC 6131454701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California Commercial |
$2.61
|
| Rate for Payer: Blue Shield of California Commercial |
$3.95
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO |
$3.60
|
| Rate for Payer: Cigna of CA PPO |
$3.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.06
|
| Rate for Payer: EPIC Health Plan Senior |
$2.06
|
| Rate for Payer: Galaxy Health WC |
$4.37
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$4.11
|
| Rate for Payer: Networks By Design Commercial |
$3.34
|
| Rate for Payer: Prime Health Services Commercial |
$4.37
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
OP
|
$2.38
|
|
|
Service Code
|
NDC 7006942101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.53
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: EPIC Health Plan Senior |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.02
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.67
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.19
|
| Rate for Payer: United Healthcare All Other HMO |
$1.19
|
| Rate for Payer: United Healthcare HMO Rider |
$1.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.02
|
| Rate for Payer: Vantage Medical Group Senior |
$2.02
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 7071011573
|
| 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 |
$0.66
|
| Rate for Payer: Blue Shield of California Commercial |
$1.01
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| 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
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 7071011573
|
| 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 |
$0.84
|
| Rate for Payer: Cash Price |
$0.59
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| 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 10 MG TABLET [23872]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 6050525021
|
| 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 |
$1.62
|
| Rate for Payer: Blue Shield of California Commercial |
$2.46
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.89
|
| 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
|
$3.20
|
|
|
Service Code
|
NDC 6050525021
|
| 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 |
$2.05
|
| Rate for Payer: Cash Price |
$1.44
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.89
|
| 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 20 MG TABLET [23873]
|
Facility
|
OP
|
$3.32
|
|
|
Service Code
|
NDC 6050525031
|
| 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 |
$2.13
|
| Rate for Payer: Cash Price |
$1.49
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.96
|
| 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
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 2315504403
|
| 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 |
$0.56
|
| Rate for Payer: Cash Price |
$0.40
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.52
|
| 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
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 6233206230
|
| 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 |
$0.66
|
| Rate for Payer: Blue Shield of California Commercial |
$1.01
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| 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 6233206230
|
| 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 |
$0.84
|
| Rate for Payer: Cash Price |
$0.59
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| 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 6050525031
|
| 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 |
$1.68
|
| Rate for Payer: Blue Shield of California Commercial |
$2.55
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.96
|
| 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
|
$0.88
|
|
|
Service Code
|
NDC 2315504403
|
| 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 |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.52
|
| 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
|
|
|
LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; MULTIPLE TENDONS (THROUGH SAME INCISION), EACH
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 27686
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$495.99 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,208.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,716.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,454.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2,942.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,629.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,208.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,943.76
|
| Rate for Payer: EPIC Health Plan Senior |
$4,629.17
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,901.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$495.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$560.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,891.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,302.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,639.18
|
| Rate for Payer: Multiplan WC |
$6,568.63
|
| Rate for Payer: Prime Health Services WC |
$6,501.60
|
| Rate for Payer: United Healthcare All Other HMO |
$20,902.00
|
| Rate for Payer: United Healthcare HMO Rider |
$13,066.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,971.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,208.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4,208.34
|
|
|
LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 27685
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$495.99 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Dignity Health Medi-Cal |
$4,629.17
|
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,208.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,454.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2,942.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,208.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,943.76
|
| Rate for Payer: EPIC Health Plan Senior |
$4,629.17
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,901.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$495.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$560.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,891.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,302.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,639.18
|
| Rate for Payer: Multiplan WC |
$6,568.63
|
| Rate for Payer: Prime Health Services WC |
$6,501.60
|
| Rate for Payer: United Healthcare All Other HMO |
$20,902.00
|
| Rate for Payer: United Healthcare HMO Rider |
$13,066.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,971.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,208.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4,208.34
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
OP
|
$19.44
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$16.52 |
| Rate for Payer: Adventist Health Commercial |
$3.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$12.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.58
|
| Rate for Payer: Cash Price |
$8.75
|
| Rate for Payer: Cigna of CA HMO |
$13.61
|
| Rate for Payer: Cigna of CA PPO |
$13.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$13.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.78
|
| Rate for Payer: EPIC Health Plan Senior |
$7.78
|
| Rate for Payer: Galaxy Health WC |
$16.52
|
| Rate for Payer: Global Benefits Group Commercial |
$11.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.61
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.61
|
| Rate for Payer: Multiplan Commercial |
$15.55
|
| Rate for Payer: Networks By Design Commercial |
$9.72
|
| Rate for Payer: Prime Health Services Commercial |
$16.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.30
|
| Rate for Payer: United Healthcare All Other HMO |
$7.10
|
| Rate for Payer: United Healthcare HMO Rider |
$6.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.52
|
| Rate for Payer: Vantage Medical Group Senior |
$16.52
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
IP
|
$19.44
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$16.52 |
| Rate for Payer: Adventist Health Commercial |
$3.89
|
| Rate for Payer: Blue Shield of California Commercial |
$14.95
|
| Rate for Payer: Blue Shield of California Commercial |
$9.86
|
| Rate for Payer: Cash Price |
$8.75
|
| Rate for Payer: Cigna of CA HMO |
$13.61
|
| Rate for Payer: Cigna of CA PPO |
$13.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$13.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.78
|
| Rate for Payer: EPIC Health Plan Senior |
$7.78
|
| Rate for Payer: Galaxy Health WC |
$16.52
|
| Rate for Payer: Global Benefits Group Commercial |
$11.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.67
|
| Rate for Payer: Multiplan Commercial |
$15.55
|
| Rate for Payer: Networks By Design Commercial |
$9.72
|
| Rate for Payer: Prime Health Services Commercial |
$16.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.30
|
| Rate for Payer: United Healthcare All Other HMO |
$7.10
|
| Rate for Payer: United Healthcare HMO Rider |
$6.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.37
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
OP
|
$337.50
|
|
|
Service Code
|
NDC 0006307604
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.50 |
| Max. Negotiated Rate |
$286.88 |
| Rate for Payer: Adventist Health Commercial |
$67.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$221.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$286.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$185.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$253.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$216.57
|
| Rate for Payer: Cash Price |
$151.88
|
| Rate for Payer: Cigna of CA HMO |
$236.25
|
| Rate for Payer: Cigna of CA PPO |
$236.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$286.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$286.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$286.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$236.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.00
|
| Rate for Payer: EPIC Health Plan Senior |
$135.00
|
| Rate for Payer: Galaxy Health WC |
$286.88
|
| Rate for Payer: Global Benefits Group Commercial |
$202.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$214.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$122.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$199.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$236.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$236.25
|
| Rate for Payer: Multiplan Commercial |
$270.00
|
| Rate for Payer: Networks By Design Commercial |
$219.38
|
| Rate for Payer: Prime Health Services Commercial |
$286.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$202.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$202.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$168.75
|
| Rate for Payer: United Healthcare All Other HMO |
$168.75
|
| Rate for Payer: United Healthcare HMO Rider |
$168.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$168.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$286.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$286.88
|
| Rate for Payer: Vantage Medical Group Senior |
$286.88
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
IP
|
$337.50
|
|
|
Service Code
|
NDC 0006307604
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.50 |
| Max. Negotiated Rate |
$286.88 |
| Rate for Payer: Adventist Health Commercial |
$67.50
|
| Rate for Payer: Blue Shield of California Commercial |
$171.11
|
| Rate for Payer: Blue Shield of California Commercial |
$259.54
|
| Rate for Payer: Cash Price |
$151.88
|
| Rate for Payer: Cigna of CA HMO |
$236.25
|
| Rate for Payer: Cigna of CA PPO |
$236.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$236.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.00
|
| Rate for Payer: EPIC Health Plan Senior |
$135.00
|
| Rate for Payer: Galaxy Health WC |
$286.88
|
| Rate for Payer: Global Benefits Group Commercial |
$202.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$214.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$199.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.00
|
| Rate for Payer: Multiplan Commercial |
$270.00
|
| Rate for Payer: Networks By Design Commercial |
$219.38
|
| Rate for Payer: Prime Health Services Commercial |
$286.88
|
|
