|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
|
OP
|
$123.47
|
|
|
Service Code
|
NDC 0078-0469-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$24.69 |
| Max. Negotiated Rate |
$104.95 |
| Rate for Payer: Adventist Health Commercial |
$24.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$80.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$104.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$67.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$92.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.82
|
| Rate for Payer: Cash Price |
$67.91
|
| Rate for Payer: Cigna of CA HMO |
$86.43
|
| Rate for Payer: Cigna of CA PPO |
$86.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$104.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$104.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$104.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$49.39
|
| Rate for Payer: EPIC Health Plan Senior |
$49.39
|
| Rate for Payer: Galaxy Health WC |
$104.95
|
| Rate for Payer: Global Benefits Group Commercial |
$74.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$82.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$76.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$86.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$86.43
|
| Rate for Payer: Multiplan Commercial |
$98.78
|
| Rate for Payer: Networks By Design Commercial |
$80.26
|
| Rate for Payer: Prime Health Services Commercial |
$104.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$74.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$74.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$61.73
|
| Rate for Payer: United Healthcare All Other HMO |
$61.73
|
| Rate for Payer: United Healthcare HMO Rider |
$61.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$61.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$104.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$104.95
|
| Rate for Payer: Vantage Medical Group Senior |
$104.95
|
|
|
DEFERASIROX 360 MG TABLET [206428]
|
Facility
|
IP
|
$264.76
|
|
|
Service Code
|
NDC 0078-0656-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$52.95 |
| Max. Negotiated Rate |
$225.05 |
| Rate for Payer: Adventist Health Commercial |
$52.95
|
| Rate for Payer: Blue Shield of California Commercial |
$195.39
|
| Rate for Payer: Blue Shield of California EPN |
$128.67
|
| Rate for Payer: Cash Price |
$145.62
|
| Rate for Payer: Cigna of CA HMO |
$185.33
|
| Rate for Payer: Cigna of CA PPO |
$185.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$105.90
|
| Rate for Payer: EPIC Health Plan Senior |
$105.90
|
| Rate for Payer: Galaxy Health WC |
$225.05
|
| Rate for Payer: Global Benefits Group Commercial |
$158.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$176.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$100.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$163.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.54
|
| Rate for Payer: Multiplan Commercial |
$211.81
|
| Rate for Payer: Networks By Design Commercial |
$172.09
|
| Rate for Payer: Prime Health Services Commercial |
$225.05
|
|
|
DEFERASIROX 360 MG TABLET [206428]
|
Facility
|
OP
|
$264.76
|
|
|
Service Code
|
NDC 0078-0656-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$52.95 |
| Max. Negotiated Rate |
$225.05 |
| Rate for Payer: Adventist Health Commercial |
$52.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$173.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$225.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$145.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$198.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$162.59
|
| Rate for Payer: Cash Price |
$145.62
|
| Rate for Payer: Cigna of CA HMO |
$185.33
|
| Rate for Payer: Cigna of CA PPO |
$185.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$225.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$225.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$225.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$105.90
|
| Rate for Payer: EPIC Health Plan Senior |
$105.90
|
| Rate for Payer: Galaxy Health WC |
$225.05
|
| Rate for Payer: Global Benefits Group Commercial |
$158.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$176.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$100.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$163.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$185.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$185.33
|
| Rate for Payer: Multiplan Commercial |
$211.81
|
| Rate for Payer: Networks By Design Commercial |
$172.09
|
| Rate for Payer: Prime Health Services Commercial |
$225.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$158.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$158.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$132.38
|
| Rate for Payer: United Healthcare All Other HMO |
$132.38
|
| Rate for Payer: United Healthcare HMO Rider |
$132.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$132.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$225.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$225.05
|
| Rate for Payer: Vantage Medical Group Senior |
$225.05
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
|
IP
|
$246.93
|
|
|
Service Code
|
NDC 0078-0470-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.39 |
| Max. Negotiated Rate |
$209.89 |
| Rate for Payer: Adventist Health Commercial |
$49.39
|
| Rate for Payer: Blue Shield of California Commercial |
$182.23
|
| Rate for Payer: Blue Shield of California EPN |
$120.01
|
| Rate for Payer: Cash Price |
$135.81
|
| Rate for Payer: Cigna of CA HMO |
$172.85
|
| Rate for Payer: Cigna of CA PPO |
$172.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$98.77
|
| Rate for Payer: EPIC Health Plan Senior |
$98.77
|
| Rate for Payer: Galaxy Health WC |
$209.89
|
| Rate for Payer: Global Benefits Group Commercial |
$148.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$164.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$94.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$152.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.26
|
| Rate for Payer: Multiplan Commercial |
$197.54
|
| Rate for Payer: Networks By Design Commercial |
$160.50
|
| Rate for Payer: Prime Health Services Commercial |
$209.89
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
|
OP
|
$246.93
|
|
|
Service Code
|
NDC 0078-0470-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.39 |
| Max. Negotiated Rate |
$209.89 |
| Rate for Payer: Adventist Health Commercial |
$49.39
|
| Rate for Payer: Aetna of CA HMO/PPO |
$161.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$209.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$135.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$185.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$151.64
|
| Rate for Payer: Cash Price |
$135.81
|
| Rate for Payer: Cigna of CA HMO |
$172.85
|
| Rate for Payer: Cigna of CA PPO |
$172.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$209.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$209.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$209.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$98.77
|
| Rate for Payer: EPIC Health Plan Senior |
$98.77
|
| Rate for Payer: Galaxy Health WC |
$209.89
|
| Rate for Payer: Global Benefits Group Commercial |
$148.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$164.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$94.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$152.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$172.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$172.85
|
| Rate for Payer: Multiplan Commercial |
$197.54
|
| Rate for Payer: Networks By Design Commercial |
$160.50
|
| Rate for Payer: Prime Health Services Commercial |
$209.89
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$148.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$148.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$123.47
|
| Rate for Payer: United Healthcare All Other HMO |
$123.47
|
| Rate for Payer: United Healthcare HMO Rider |
$123.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$123.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$209.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$209.89
|
| Rate for Payer: Vantage Medical Group Senior |
$209.89
|
|
|
DEFERASIROX 90 MG TABLET [206426]
|
Facility
|
OP
|
$66.19
|
|
|
Service Code
|
NDC 0078-0654-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.24 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: Adventist Health Commercial |
$13.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$43.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$56.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$36.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$40.65
|
| Rate for Payer: Cash Price |
$36.41
|
| Rate for Payer: Cigna of CA HMO |
$46.33
|
| Rate for Payer: Cigna of CA PPO |
$46.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$56.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$56.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$56.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.48
|
| Rate for Payer: EPIC Health Plan Senior |
$26.48
|
| Rate for Payer: Galaxy Health WC |
$56.26
|
| Rate for Payer: Global Benefits Group Commercial |
$39.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$44.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$40.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$46.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$46.33
|
| Rate for Payer: Multiplan Commercial |
$52.95
|
| Rate for Payer: Networks By Design Commercial |
$43.02
|
| Rate for Payer: Prime Health Services Commercial |
$56.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$39.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$39.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$33.09
|
| Rate for Payer: United Healthcare All Other HMO |
$33.09
|
| Rate for Payer: United Healthcare HMO Rider |
$33.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$56.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$56.26
|
| Rate for Payer: Vantage Medical Group Senior |
$56.26
|
|
|
DEFERASIROX 90 MG TABLET [206426]
|
Facility
|
IP
|
$66.19
|
|
|
Service Code
|
NDC 0078-0654-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.24 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: Adventist Health Commercial |
$13.24
|
| Rate for Payer: Blue Shield of California Commercial |
$48.85
|
| Rate for Payer: Blue Shield of California EPN |
$32.17
|
| Rate for Payer: Cash Price |
$36.41
|
| Rate for Payer: Cigna of CA HMO |
$46.33
|
| Rate for Payer: Cigna of CA PPO |
$46.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.48
|
| Rate for Payer: EPIC Health Plan Senior |
$26.48
|
| Rate for Payer: Galaxy Health WC |
$56.26
|
| Rate for Payer: Global Benefits Group Commercial |
$39.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$44.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$40.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.89
|
| Rate for Payer: Multiplan Commercial |
$52.95
|
| Rate for Payer: Networks By Design Commercial |
$43.02
|
| Rate for Payer: Prime Health Services Commercial |
$56.26
|
|
|
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]
|
Facility
|
IP
|
$49.44
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.89 |
| Max. Negotiated Rate |
$42.02 |
| Rate for Payer: Adventist Health Commercial |
$9.89
|
| Rate for Payer: Blue Shield of California Commercial |
$36.49
|
| Rate for Payer: Blue Shield of California EPN |
$24.03
|
| Rate for Payer: Cash Price |
$27.19
|
| Rate for Payer: Cigna of CA HMO |
$34.61
|
| Rate for Payer: Cigna of CA PPO |
$34.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.78
|
| Rate for Payer: EPIC Health Plan Senior |
$19.78
|
| Rate for Payer: Galaxy Health WC |
$42.02
|
| Rate for Payer: Global Benefits Group Commercial |
$29.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$30.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.87
|
| Rate for Payer: Multiplan Commercial |
$39.55
|
| Rate for Payer: Networks By Design Commercial |
$24.72
|
| Rate for Payer: Prime Health Services Commercial |
$42.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.55
|
| Rate for Payer: United Healthcare All Other HMO |
$18.06
|
| Rate for Payer: United Healthcare HMO Rider |
$17.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.19
|
|
|
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]
|
Facility
|
OP
|
$49.44
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.21 |
| Max. Negotiated Rate |
$42.02 |
| Rate for Payer: Adventist Health Commercial |
$9.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$32.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.53
|
| Rate for Payer: Blue Shield of California Commercial |
$13.56
|
| Rate for Payer: Blue Shield of California EPN |
$13.56
|
| Rate for Payer: Cash Price |
$27.19
|
| Rate for Payer: Cash Price |
$27.19
|
| Rate for Payer: Cigna of CA HMO |
$34.61
|
| Rate for Payer: Cigna of CA PPO |
$34.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$42.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.78
|
| Rate for Payer: EPIC Health Plan Senior |
$19.78
|
| Rate for Payer: Galaxy Health WC |
$42.02
|
| Rate for Payer: Global Benefits Group Commercial |
$29.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$30.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$34.61
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$34.61
|
| Rate for Payer: Multiplan Commercial |
$39.55
|
| Rate for Payer: Networks By Design Commercial |
$24.72
|
| Rate for Payer: Prime Health Services Commercial |
$42.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$29.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$29.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.55
|
| Rate for Payer: United Healthcare All Other HMO |
$18.06
|
| Rate for Payer: United Healthcare HMO Rider |
$17.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.02
|
| Rate for Payer: Vantage Medical Group Senior |
$42.02
|
|
|
DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]
|
Facility
|
IP
|
$17.71
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$15.05 |
| Rate for Payer: Adventist Health Commercial |
$3.54
|
| Rate for Payer: Blue Shield of California Commercial |
$13.07
|
| Rate for Payer: Blue Shield of California EPN |
$8.61
|
| Rate for Payer: Cash Price |
$9.74
|
| Rate for Payer: Cigna of CA HMO |
$12.40
|
| Rate for Payer: Cigna of CA PPO |
$12.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.08
|
| Rate for Payer: EPIC Health Plan Senior |
$7.08
|
| Rate for Payer: Galaxy Health WC |
$15.05
|
| Rate for Payer: Global Benefits Group Commercial |
$10.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Multiplan Commercial |
$14.17
|
| Rate for Payer: Networks By Design Commercial |
$8.86
|
| Rate for Payer: Prime Health Services Commercial |
$15.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.65
|
| Rate for Payer: United Healthcare All Other HMO |
$6.47
|
| Rate for Payer: United Healthcare HMO Rider |
$6.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.80
|
|
|
DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]
|
Facility
|
OP
|
$17.71
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Adventist Health Commercial |
$3.54
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.53
|
| Rate for Payer: Blue Shield of California Commercial |
$13.56
|
| Rate for Payer: Blue Shield of California EPN |
$13.56
|
| Rate for Payer: Cash Price |
$9.74
|
| Rate for Payer: Cash Price |
$9.74
|
| Rate for Payer: Cigna of CA HMO |
$12.40
|
| Rate for Payer: Cigna of CA PPO |
$12.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.08
|
| Rate for Payer: EPIC Health Plan Senior |
$7.08
|
| Rate for Payer: Galaxy Health WC |
$15.05
|
| Rate for Payer: Global Benefits Group Commercial |
$10.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.40
|
| Rate for Payer: Multiplan Commercial |
$14.17
|
| Rate for Payer: Networks By Design Commercial |
$8.86
|
| Rate for Payer: Prime Health Services Commercial |
$15.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.65
|
| Rate for Payer: United Healthcare All Other HMO |
$6.47
|
| Rate for Payer: United Healthcare HMO Rider |
$6.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.05
|
| Rate for Payer: Vantage Medical Group Senior |
$15.05
|
|
|
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION [9723]
|
Facility
|
OP
|
$15.54
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: United Healthcare HMO Rider |
$5.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.05
|
| Rate for Payer: Vantage Medical Group Senior |
$13.21
|
| Rate for Payer: Vantage Medical Group Senior |
$15.05
|
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Adventist Health Commercial |
$3.54
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.53
|
| Rate for Payer: Blue Shield of California Commercial |
$13.56
|
| Rate for Payer: Blue Shield of California Commercial |
$13.56
|
| Rate for Payer: Blue Shield of California EPN |
$13.56
|
| Rate for Payer: Blue Shield of California EPN |
$13.56
|
| Rate for Payer: Cash Price |
$8.55
|
| Rate for Payer: Cash Price |
$9.74
|
| Rate for Payer: Cash Price |
$8.55
|
| Rate for Payer: Cash Price |
$9.74
|
| Rate for Payer: Cigna of CA HMO |
$12.40
|
| Rate for Payer: Cigna of CA HMO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$12.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.08
|
| Rate for Payer: EPIC Health Plan Senior |
$7.08
|
| Rate for Payer: EPIC Health Plan Senior |
$6.22
|
| Rate for Payer: Galaxy Health WC |
$15.05
|
| Rate for Payer: Galaxy Health WC |
$13.21
|
| Rate for Payer: Global Benefits Group Commercial |
$10.63
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.40
|
| Rate for Payer: Multiplan Commercial |
$14.17
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
| Rate for Payer: Networks By Design Commercial |
$8.86
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$13.21
|
| Rate for Payer: Prime Health Services Commercial |
$15.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.65
|
| Rate for Payer: United Healthcare All Other HMO |
$5.68
|
| Rate for Payer: United Healthcare All Other HMO |
$6.47
|
| Rate for Payer: United Healthcare HMO Rider |
$6.33
|
|
|
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION [9723]
|
Facility
|
IP
|
$17.71
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$15.05 |
| Rate for Payer: Adventist Health Commercial |
$3.54
|
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Blue Shield of California Commercial |
$13.07
|
| Rate for Payer: Blue Shield of California Commercial |
$11.47
|
| Rate for Payer: Blue Shield of California EPN |
$7.55
|
| Rate for Payer: Blue Shield of California EPN |
$8.61
|
| Rate for Payer: Cash Price |
$9.74
|
| Rate for Payer: Cash Price |
$8.55
|
| Rate for Payer: Cigna of CA HMO |
$12.40
|
| Rate for Payer: Cigna of CA HMO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$12.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.08
|
| Rate for Payer: EPIC Health Plan Senior |
$6.22
|
| Rate for Payer: EPIC Health Plan Senior |
$7.08
|
| Rate for Payer: Galaxy Health WC |
$13.21
|
| Rate for Payer: Galaxy Health WC |
$15.05
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Global Benefits Group Commercial |
$10.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
| Rate for Payer: Multiplan Commercial |
$14.17
|
| Rate for Payer: Networks By Design Commercial |
$8.86
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$15.05
|
| Rate for Payer: Prime Health Services Commercial |
$13.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.65
|
| Rate for Payer: United Healthcare All Other HMO |
$6.47
|
| Rate for Payer: United Healthcare All Other HMO |
$5.68
|
| Rate for Payer: United Healthcare HMO Rider |
$5.55
|
| Rate for Payer: United Healthcare HMO Rider |
$6.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.80
|
|
|
DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION [214034]
|
Facility
|
IP
|
$573.60
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.72 |
| Max. Negotiated Rate |
$487.56 |
| Rate for Payer: Adventist Health Commercial |
$114.72
|
| Rate for Payer: Blue Shield of California Commercial |
$423.32
|
| Rate for Payer: Blue Shield of California EPN |
$278.77
|
| Rate for Payer: Cash Price |
$315.48
|
| Rate for Payer: Cigna of CA HMO |
$401.52
|
| Rate for Payer: Cigna of CA PPO |
$401.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$229.44
|
| Rate for Payer: EPIC Health Plan Senior |
$229.44
|
| Rate for Payer: Galaxy Health WC |
$487.56
|
| Rate for Payer: Global Benefits Group Commercial |
$344.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$382.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$218.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$355.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.66
|
| Rate for Payer: Multiplan Commercial |
$458.88
|
| Rate for Payer: Networks By Design Commercial |
$286.80
|
| Rate for Payer: Prime Health Services Commercial |
$487.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$215.27
|
| Rate for Payer: United Healthcare All Other HMO |
$209.54
|
| Rate for Payer: United Healthcare HMO Rider |
$205.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$187.85
|
|
|
DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION [214034]
|
Facility
|
OP
|
$573.60
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.72 |
| Max. Negotiated Rate |
$487.56 |
| Rate for Payer: Adventist Health Commercial |
$114.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$376.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$487.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$315.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$430.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$352.25
|
| Rate for Payer: Cash Price |
$315.48
|
| Rate for Payer: Cigna of CA HMO |
$401.52
|
| Rate for Payer: Cigna of CA PPO |
$401.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$487.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$487.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$487.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$229.44
|
| Rate for Payer: EPIC Health Plan Senior |
$229.44
|
| Rate for Payer: Galaxy Health WC |
$487.56
|
| Rate for Payer: Global Benefits Group Commercial |
$344.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$382.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$355.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$401.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$401.52
|
| Rate for Payer: Multiplan Commercial |
$458.88
|
| Rate for Payer: Networks By Design Commercial |
$286.80
|
| Rate for Payer: Prime Health Services Commercial |
$487.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$344.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$344.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$215.27
|
| Rate for Payer: United Healthcare All Other HMO |
$209.54
|
| Rate for Payer: United Healthcare HMO Rider |
$205.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$187.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$487.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$487.56
|
| Rate for Payer: Vantage Medical Group Senior |
$487.56
|
|
|
DEGARELIX 80 MG SUBCUTANEOUS SOLUTION [96986]
|
Facility
|
OP
|
$586.14
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$498.22 |
| Rate for Payer: Adventist Health Commercial |
$117.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$384.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.59
|
| Rate for Payer: Blue Shield of California Commercial |
$7.33
|
| Rate for Payer: Blue Shield of California EPN |
$7.33
|
| Rate for Payer: Cash Price |
$322.38
|
| Rate for Payer: Cash Price |
$322.38
|
| Rate for Payer: Cigna of CA HMO |
$410.30
|
| Rate for Payer: Cigna of CA PPO |
$410.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.89
|
| Rate for Payer: EPIC Health Plan Senior |
$4.36
|
| Rate for Payer: Galaxy Health WC |
$498.22
|
| Rate for Payer: Global Benefits Group Commercial |
$351.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$390.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$140.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.84
|
| Rate for Payer: Multiplan Commercial |
$468.91
|
| Rate for Payer: Networks By Design Commercial |
$293.07
|
| Rate for Payer: Prime Health Services Commercial |
$498.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$351.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$351.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$219.98
|
| Rate for Payer: United Healthcare All Other HMO |
$214.12
|
| Rate for Payer: United Healthcare HMO Rider |
$209.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$191.96
|
| Rate for Payer: Upland Medical Group Pediatric |
$4.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.80
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
|
|
DEGARELIX 80 MG SUBCUTANEOUS SOLUTION [96986]
|
Facility
|
IP
|
$586.14
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$117.23 |
| Max. Negotiated Rate |
$498.22 |
| Rate for Payer: Adventist Health Commercial |
$117.23
|
| Rate for Payer: Blue Shield of California Commercial |
$432.57
|
| Rate for Payer: Blue Shield of California EPN |
$284.86
|
| Rate for Payer: Cash Price |
$322.38
|
| Rate for Payer: Cigna of CA HMO |
$410.30
|
| Rate for Payer: Cigna of CA PPO |
$410.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$234.46
|
| Rate for Payer: EPIC Health Plan Senior |
$234.46
|
| Rate for Payer: Galaxy Health WC |
$498.22
|
| Rate for Payer: Global Benefits Group Commercial |
$351.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$390.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$223.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$362.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$140.67
|
| Rate for Payer: Multiplan Commercial |
$468.91
|
| Rate for Payer: Networks By Design Commercial |
$293.07
|
| Rate for Payer: Prime Health Services Commercial |
$498.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$219.98
|
| Rate for Payer: United Healthcare All Other HMO |
$214.12
|
| Rate for Payer: United Healthcare HMO Rider |
$209.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$191.96
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 50742-113-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 45963-342-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.94
|
| Rate for Payer: Cigna of CA PPO |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Networks By Design Commercial |
$0.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.14
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 50742-113-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 45963-342-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Networks By Design Commercial |
$0.87
|
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.82
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.94
|
| Rate for Payer: Cigna of CA PPO |
$0.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.67
|
| Rate for Payer: United Healthcare All Other HMO |
$0.67
|
| Rate for Payer: United Healthcare HMO Rider |
$0.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
DESMOPRESSIN 0.1 MG TABLET [16052]
|
Facility
|
IP
|
$2.63
|
|
|
Service Code
|
NDC 60687-721-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$1.94
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Cigna of CA HMO |
$1.84
|
| Rate for Payer: Cigna of CA PPO |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: EPIC Health Plan Senior |
$1.05
|
| Rate for Payer: Galaxy Health WC |
$2.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$2.10
|
| Rate for Payer: Networks By Design Commercial |
$1.71
|
| Rate for Payer: Prime Health Services Commercial |
$2.24
|
|
|
DESMOPRESSIN 0.1 MG TABLET [16052]
|
Facility
|
IP
|
$2.63
|
|
|
Service Code
|
NDC 60687-721-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$1.94
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Cigna of CA HMO |
$1.84
|
| Rate for Payer: Cigna of CA PPO |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: EPIC Health Plan Senior |
$1.05
|
| Rate for Payer: Galaxy Health WC |
$2.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$2.10
|
| Rate for Payer: Networks By Design Commercial |
$1.71
|
| Rate for Payer: Prime Health Services Commercial |
$2.24
|
|
|
DESMOPRESSIN 0.1 MG TABLET [16052]
|
Facility
|
OP
|
$2.63
|
|
|
Service Code
|
NDC 60687-721-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.62
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Cigna of CA HMO |
$1.84
|
| Rate for Payer: Cigna of CA PPO |
$1.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: EPIC Health Plan Senior |
$1.05
|
| Rate for Payer: Galaxy Health WC |
$2.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$2.10
|
| Rate for Payer: Networks By Design Commercial |
$1.71
|
| Rate for Payer: Prime Health Services Commercial |
$2.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.31
|
| Rate for Payer: United Healthcare All Other HMO |
$1.31
|
| Rate for Payer: United Healthcare HMO Rider |
$1.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Vantage Medical Group Senior |
$2.24
|
|
|
DESMOPRESSIN 0.1 MG TABLET [16052]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 68001-574-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Senior |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.75
|
|
