|
BORTEZOMIB 3.5 MG INTRAVENOUS POWDER FOR SOLUTION [220799]
|
Facility
|
OP
|
$1,923.58
|
|
|
Service Code
|
HCPCS J9048
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$1,635.04 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$284.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.07
|
| Rate for Payer: Blue Shield of California Commercial |
$54.96
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Cigna of CA HMO |
$1,346.51
|
| Rate for Payer: Cigna of CA PPO |
$1,346.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.67
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,346.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.50
|
| Rate for Payer: EPIC Health Plan Senior |
$7.67
|
| Rate for Payer: Galaxy Health WC |
$1,635.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1,154.15
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$11.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$84.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,221.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$95.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$461.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$1,538.86
|
| Rate for Payer: Networks By Design Commercial |
$961.79
|
| Rate for Payer: Prime Health Services Commercial |
$1,635.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,154.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,154.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$721.92
|
| Rate for Payer: United Healthcare All Other HMO |
$702.68
|
| Rate for Payer: United Healthcare HMO Rider |
$687.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$629.97
|
| Rate for Payer: Upland Medical Group Pediatric |
$6.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.67
|
| Rate for Payer: Vantage Medical Group Senior |
$7.67
|
|
|
BORTEZOMIB 3.5 MG IV INJECTION. [408035839]
|
Facility
|
IP
|
$1,923.58
|
|
|
Service Code
|
HCPCS J9048
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$384.72 |
| Max. Negotiated Rate |
$1,635.04 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Blue Shield of California Commercial |
$1,479.23
|
| Rate for Payer: Blue Shield of California Commercial |
$975.26
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Cigna of CA HMO |
$1,346.51
|
| Rate for Payer: Cigna of CA PPO |
$1,346.51
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,346.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$769.43
|
| Rate for Payer: EPIC Health Plan Senior |
$769.43
|
| Rate for Payer: Galaxy Health WC |
$1,635.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1,154.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,221.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,134.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$461.66
|
| Rate for Payer: Multiplan Commercial |
$1,538.86
|
| Rate for Payer: Networks By Design Commercial |
$961.79
|
| Rate for Payer: Prime Health Services Commercial |
$1,635.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$721.92
|
| Rate for Payer: United Healthcare All Other HMO |
$702.68
|
| Rate for Payer: United Healthcare HMO Rider |
$687.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$629.97
|
|
|
BORTEZOMIB 3.5 MG IV INJECTION. [408035839]
|
Facility
|
OP
|
$1,923.58
|
|
|
Service Code
|
HCPCS J9048
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$1,635.04 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$284.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.07
|
| Rate for Payer: Blue Shield of California Commercial |
$54.96
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Cigna of CA HMO |
$1,346.51
|
| Rate for Payer: Cigna of CA PPO |
$1,346.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.67
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,346.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.50
|
| Rate for Payer: EPIC Health Plan Senior |
$7.67
|
| Rate for Payer: Galaxy Health WC |
$1,635.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1,154.15
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$11.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$84.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,221.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$95.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$461.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$1,538.86
|
| Rate for Payer: Networks By Design Commercial |
$961.79
|
| Rate for Payer: Prime Health Services Commercial |
$1,635.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,154.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,154.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$721.92
|
| Rate for Payer: United Healthcare All Other HMO |
$702.68
|
| Rate for Payer: United Healthcare HMO Rider |
$687.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$629.97
|
| Rate for Payer: Upland Medical Group Pediatric |
$6.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.67
|
| Rate for Payer: Vantage Medical Group Senior |
$7.67
|
|
|
BORTEZOMIB 3.5 MG IV INJECTION. [408035839]
|
Facility
|
OP
|
$1,923.60
|
|
|
Service Code
|
HCPCS J9041
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$1,635.06 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,635.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,057.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,442.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.86
|
| Rate for Payer: Blue Shield of California Commercial |
$4.40
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cigna of CA HMO |
$1,346.52
|
| Rate for Payer: Cigna of CA PPO |
$1,346.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,635.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,635.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,635.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,346.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$769.44
|
| Rate for Payer: EPIC Health Plan Senior |
$769.44
|
| Rate for Payer: Galaxy Health WC |
$1,635.06
|
| Rate for Payer: Global Benefits Group Commercial |
$1,154.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,221.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,134.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$461.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,346.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,346.52
|
| Rate for Payer: Multiplan Commercial |
$1,538.88
|
| Rate for Payer: Networks By Design Commercial |
$961.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,635.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,154.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,154.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$721.93
|
| Rate for Payer: United Healthcare All Other HMO |
$702.69
|
| Rate for Payer: United Healthcare HMO Rider |
$687.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$629.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,635.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,635.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1,635.06
|
|
|
BORTEZOMIB 3.5 MG IV INJECTION. [408035839]
|
Facility
|
IP
|
$1,923.60
|
|
|
Service Code
|
HCPCS J9041
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$384.72 |
| Max. Negotiated Rate |
$1,635.06 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Blue Shield of California Commercial |
$1,479.25
|
| Rate for Payer: Blue Shield of California Commercial |
$975.27
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cigna of CA HMO |
$1,346.52
|
| Rate for Payer: Cigna of CA PPO |
$1,346.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,346.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$769.44
|
| Rate for Payer: EPIC Health Plan Senior |
$769.44
|
| Rate for Payer: Galaxy Health WC |
$1,635.06
|
| Rate for Payer: Global Benefits Group Commercial |
$1,154.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,221.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,134.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$461.66
|
| Rate for Payer: Multiplan Commercial |
$1,538.88
|
| Rate for Payer: Networks By Design Commercial |
$961.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,635.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$721.93
|
| Rate for Payer: United Healthcare All Other HMO |
$702.69
|
| Rate for Payer: United Healthcare HMO Rider |
$687.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$629.98
|
|
|
BORTEZOMIB 3.5 MG SOLUTION FOR INJECTION SQ [40835839]
|
Facility
|
IP
|
$1,923.60
|
|
|
Service Code
|
HCPCS J9041
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$384.72 |
| Max. Negotiated Rate |
$1,635.06 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Blue Shield of California Commercial |
$1,479.25
|
| Rate for Payer: Blue Shield of California Commercial |
$975.27
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cigna of CA HMO |
$1,346.52
|
| Rate for Payer: Cigna of CA PPO |
$1,346.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,346.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$769.44
|
| Rate for Payer: EPIC Health Plan Senior |
$769.44
|
| Rate for Payer: Galaxy Health WC |
$1,635.06
|
| Rate for Payer: Global Benefits Group Commercial |
$1,154.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,221.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,134.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$461.66
|
| Rate for Payer: Multiplan Commercial |
$1,538.88
|
| Rate for Payer: Networks By Design Commercial |
$961.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,635.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$721.93
|
| Rate for Payer: United Healthcare All Other HMO |
$702.69
|
| Rate for Payer: United Healthcare HMO Rider |
$687.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$629.98
|
|
|
BORTEZOMIB 3.5 MG SOLUTION FOR INJECTION SQ [40835839]
|
Facility
|
OP
|
$1,923.60
|
|
|
Service Code
|
HCPCS J9041
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$1,635.06 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,635.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,057.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,442.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.86
|
| Rate for Payer: Blue Shield of California Commercial |
$4.40
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cigna of CA HMO |
$1,346.52
|
| Rate for Payer: Cigna of CA PPO |
$1,346.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,635.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,635.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,635.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,346.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$769.44
|
| Rate for Payer: EPIC Health Plan Senior |
$769.44
|
| Rate for Payer: Galaxy Health WC |
$1,635.06
|
| Rate for Payer: Global Benefits Group Commercial |
$1,154.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,221.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,134.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$461.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,346.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,346.52
|
| Rate for Payer: Multiplan Commercial |
$1,538.88
|
| Rate for Payer: Networks By Design Commercial |
$961.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,635.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,154.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,154.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$721.93
|
| Rate for Payer: United Healthcare All Other HMO |
$702.69
|
| Rate for Payer: United Healthcare HMO Rider |
$687.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$629.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,635.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,635.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1,635.06
|
|
|
BOSENTAN 125 MG TABLET [31876]
|
Facility
|
OP
|
$17.45
|
|
|
Service Code
|
NDC 6838244714
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.20
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: Cigna of CA HMO |
$12.21
|
| Rate for Payer: Cigna of CA PPO |
$12.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: EPIC Health Plan Senior |
$6.98
|
| Rate for Payer: Galaxy Health WC |
$14.83
|
| Rate for Payer: Global Benefits Group Commercial |
$10.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.21
|
| Rate for Payer: Multiplan Commercial |
$13.96
|
| Rate for Payer: Networks By Design Commercial |
$11.34
|
| Rate for Payer: Prime Health Services Commercial |
$14.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.72
|
| Rate for Payer: United Healthcare All Other HMO |
$8.72
|
| Rate for Payer: United Healthcare HMO Rider |
$8.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.83
|
|
|
BOSENTAN 125 MG TABLET [31876]
|
Facility
|
IP
|
$17.45
|
|
|
Service Code
|
NDC 6838244714
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Blue Shield of California Commercial |
$13.42
|
| Rate for Payer: Blue Shield of California Commercial |
$8.85
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: Cigna of CA HMO |
$12.21
|
| Rate for Payer: Cigna of CA PPO |
$12.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: EPIC Health Plan Senior |
$6.98
|
| Rate for Payer: Galaxy Health WC |
$14.83
|
| Rate for Payer: Global Benefits Group Commercial |
$10.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.19
|
| Rate for Payer: Multiplan Commercial |
$13.96
|
| Rate for Payer: Networks By Design Commercial |
$11.34
|
| Rate for Payer: Prime Health Services Commercial |
$14.83
|
|
|
BOSENTAN 31.25 MG 1/2 TABLET [4081538]
|
Facility
|
IP
|
$17.45
|
|
|
Service Code
|
NDC 6838244614
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Blue Shield of California Commercial |
$13.42
|
| Rate for Payer: Blue Shield of California Commercial |
$8.85
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: Cigna of CA HMO |
$12.21
|
| Rate for Payer: Cigna of CA PPO |
$12.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: EPIC Health Plan Senior |
$6.98
|
| Rate for Payer: Galaxy Health WC |
$14.83
|
| Rate for Payer: Global Benefits Group Commercial |
$10.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.19
|
| Rate for Payer: Multiplan Commercial |
$13.96
|
| Rate for Payer: Networks By Design Commercial |
$11.34
|
| Rate for Payer: Prime Health Services Commercial |
$14.83
|
|
|
BOSENTAN 31.25 MG 1/2 TABLET [4081538]
|
Facility
|
OP
|
$17.45
|
|
|
Service Code
|
NDC 6838244614
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.20
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: Cigna of CA HMO |
$12.21
|
| Rate for Payer: Cigna of CA PPO |
$12.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: EPIC Health Plan Senior |
$6.98
|
| Rate for Payer: Galaxy Health WC |
$14.83
|
| Rate for Payer: Global Benefits Group Commercial |
$10.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.21
|
| Rate for Payer: Multiplan Commercial |
$13.96
|
| Rate for Payer: Networks By Design Commercial |
$11.34
|
| Rate for Payer: Prime Health Services Commercial |
$14.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.72
|
| Rate for Payer: United Healthcare All Other HMO |
$8.72
|
| Rate for Payer: United Healthcare HMO Rider |
$8.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.83
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$276.32
|
|
|
Service Code
|
NDC 6621510103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$234.87 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$181.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$177.31
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$234.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$234.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$100.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$193.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$193.42
|
| Rate for Payer: Multiplan Commercial |
$221.06
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$165.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$165.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$138.16
|
| Rate for Payer: United Healthcare All Other HMO |
$138.16
|
| Rate for Payer: United Healthcare HMO Rider |
$138.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$138.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.87
|
| Rate for Payer: Vantage Medical Group Senior |
$234.87
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$17.45
|
|
|
Service Code
|
NDC 6838244614
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Blue Shield of California Commercial |
$13.42
|
| Rate for Payer: Blue Shield of California Commercial |
$8.85
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: Cigna of CA HMO |
$12.21
|
| Rate for Payer: Cigna of CA PPO |
$12.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: EPIC Health Plan Senior |
$6.98
|
| Rate for Payer: Galaxy Health WC |
$14.83
|
| Rate for Payer: Global Benefits Group Commercial |
$10.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.19
|
| Rate for Payer: Multiplan Commercial |
$13.96
|
| Rate for Payer: Networks By Design Commercial |
$11.34
|
| Rate for Payer: Prime Health Services Commercial |
$14.83
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$276.32
|
|
|
Service Code
|
NDC 6621510103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$234.87 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Blue Shield of California Commercial |
$140.09
|
| Rate for Payer: Blue Shield of California Commercial |
$212.49
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.32
|
| Rate for Payer: Multiplan Commercial |
$221.06
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$276.32
|
|
|
Service Code
|
NDC 6621510106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$234.87 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Blue Shield of California Commercial |
$140.09
|
| Rate for Payer: Blue Shield of California Commercial |
$212.49
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.32
|
| Rate for Payer: Multiplan Commercial |
$221.06
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$276.32
|
|
|
Service Code
|
NDC 6621510106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$234.87 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$181.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$177.31
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$234.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$234.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$100.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$193.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$193.42
|
| Rate for Payer: Multiplan Commercial |
$221.06
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$165.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$165.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$138.16
|
| Rate for Payer: United Healthcare All Other HMO |
$138.16
|
| Rate for Payer: United Healthcare HMO Rider |
$138.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$138.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.87
|
| Rate for Payer: Vantage Medical Group Senior |
$234.87
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$17.45
|
|
|
Service Code
|
NDC 6838244614
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.20
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: Cigna of CA HMO |
$12.21
|
| Rate for Payer: Cigna of CA PPO |
$12.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: EPIC Health Plan Senior |
$6.98
|
| Rate for Payer: Galaxy Health WC |
$14.83
|
| Rate for Payer: Global Benefits Group Commercial |
$10.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.21
|
| Rate for Payer: Multiplan Commercial |
$13.96
|
| Rate for Payer: Networks By Design Commercial |
$11.34
|
| Rate for Payer: Prime Health Services Commercial |
$14.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.72
|
| Rate for Payer: United Healthcare All Other HMO |
$8.72
|
| Rate for Payer: United Healthcare HMO Rider |
$8.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.83
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
IP
|
$276.32
|
|
|
Service Code
|
NDC 6621510103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$234.87 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Blue Shield of California Commercial |
$140.09
|
| Rate for Payer: Blue Shield of California Commercial |
$212.49
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.32
|
| Rate for Payer: Multiplan Commercial |
$221.06
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
OP
|
$276.32
|
|
|
Service Code
|
NDC 6621510103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$234.87 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$181.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$177.31
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$234.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$234.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$100.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$193.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$193.42
|
| Rate for Payer: Multiplan Commercial |
$221.06
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$165.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$165.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$138.16
|
| Rate for Payer: United Healthcare All Other HMO |
$138.16
|
| Rate for Payer: United Healthcare HMO Rider |
$138.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$138.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.87
|
| Rate for Payer: Vantage Medical Group Senior |
$234.87
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
OP
|
$276.32
|
|
|
Service Code
|
NDC 6621510106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$234.87 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$181.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$177.31
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$234.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$234.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$100.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$193.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$193.42
|
| Rate for Payer: Multiplan Commercial |
$221.06
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$165.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$165.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$138.16
|
| Rate for Payer: United Healthcare All Other HMO |
$138.16
|
| Rate for Payer: United Healthcare HMO Rider |
$138.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$138.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.87
|
| Rate for Payer: Vantage Medical Group Senior |
$234.87
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
IP
|
$276.32
|
|
|
Service Code
|
NDC 6621510106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$234.87 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Blue Shield of California Commercial |
$140.09
|
| Rate for Payer: Blue Shield of California Commercial |
$212.49
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.32
|
| Rate for Payer: Multiplan Commercial |
$221.06
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
|
OP
|
$16.44
|
|
|
Service Code
|
NDC 9940831876
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$13.97 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.55
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: Cigna of CA HMO |
$11.51
|
| Rate for Payer: Cigna of CA PPO |
$11.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.97
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.58
|
| Rate for Payer: EPIC Health Plan Senior |
$6.58
|
| Rate for Payer: Galaxy Health WC |
$13.97
|
| Rate for Payer: Global Benefits Group Commercial |
$9.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.51
|
| Rate for Payer: Multiplan Commercial |
$13.15
|
| Rate for Payer: Networks By Design Commercial |
$10.69
|
| Rate for Payer: Prime Health Services Commercial |
$13.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.22
|
| Rate for Payer: United Healthcare All Other HMO |
$8.22
|
| Rate for Payer: United Healthcare HMO Rider |
$8.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.97
|
| Rate for Payer: Vantage Medical Group Senior |
$13.97
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
|
IP
|
$16.44
|
|
|
Service Code
|
NDC 9940831876
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$13.97 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Blue Shield of California Commercial |
$12.64
|
| Rate for Payer: Blue Shield of California Commercial |
$8.34
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: Cigna of CA HMO |
$11.51
|
| Rate for Payer: Cigna of CA PPO |
$11.51
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.58
|
| Rate for Payer: EPIC Health Plan Senior |
$6.58
|
| Rate for Payer: Galaxy Health WC |
$13.97
|
| Rate for Payer: Global Benefits Group Commercial |
$9.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.95
|
| Rate for Payer: Multiplan Commercial |
$13.15
|
| Rate for Payer: Networks By Design Commercial |
$10.69
|
| Rate for Payer: Prime Health Services Commercial |
$13.97
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
|
OP
|
$222.48
|
|
|
Service Code
|
NDC 0069013501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$189.11 |
| Rate for Payer: Adventist Health Commercial |
$44.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$145.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$189.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$122.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$166.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$142.77
|
| Rate for Payer: Cash Price |
$100.12
|
| Rate for Payer: Cigna of CA HMO |
$155.74
|
| Rate for Payer: Cigna of CA PPO |
$155.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$189.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$189.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$189.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$155.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.99
|
| Rate for Payer: EPIC Health Plan Senior |
$88.99
|
| Rate for Payer: Galaxy Health WC |
$189.11
|
| Rate for Payer: Global Benefits Group Commercial |
$133.49
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$141.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$80.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$131.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$155.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$155.74
|
| Rate for Payer: Multiplan Commercial |
$177.98
|
| Rate for Payer: Networks By Design Commercial |
$144.61
|
| Rate for Payer: Prime Health Services Commercial |
$189.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$133.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$133.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$111.24
|
| Rate for Payer: United Healthcare All Other HMO |
$111.24
|
| Rate for Payer: United Healthcare HMO Rider |
$111.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$111.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$189.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$189.11
|
| Rate for Payer: Vantage Medical Group Senior |
$189.11
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
|
IP
|
$222.48
|
|
|
Service Code
|
NDC 0069013501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$189.11 |
| Rate for Payer: Adventist Health Commercial |
$44.50
|
| Rate for Payer: Blue Shield of California Commercial |
$112.80
|
| Rate for Payer: Blue Shield of California Commercial |
$171.09
|
| Rate for Payer: Cash Price |
$100.12
|
| Rate for Payer: Cigna of CA HMO |
$155.74
|
| Rate for Payer: Cigna of CA PPO |
$155.74
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$155.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.99
|
| Rate for Payer: EPIC Health Plan Senior |
$88.99
|
| Rate for Payer: Galaxy Health WC |
$189.11
|
| Rate for Payer: Global Benefits Group Commercial |
$133.49
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$141.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$131.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.40
|
| Rate for Payer: Multiplan Commercial |
$177.98
|
| Rate for Payer: Networks By Design Commercial |
$144.61
|
| Rate for Payer: Prime Health Services Commercial |
$189.11
|
|
