|
DAPAGLIFLOZIN 10 MG TABLET [204693]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 0781599031
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO |
$0.70
|
| Rate for Payer: Cigna of CA PPO |
$0.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Senior |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.85
|
| Rate for Payer: Global Benefits Group Commercial |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: Networks By Design Commercial |
$0.65
|
| Rate for Payer: Prime Health Services Commercial |
$0.85
|
|
|
DAPSONE 100 MG TABLET [2131]
|
Facility
|
IP
|
$1.86
|
|
|
Service Code
|
NDC 6498056603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$1.43
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cigna of CA HMO |
$1.30
|
| Rate for Payer: Cigna of CA PPO |
$1.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: EPIC Health Plan Senior |
$0.74
|
| Rate for Payer: Galaxy Health WC |
$1.58
|
| Rate for Payer: Global Benefits Group Commercial |
$1.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.49
|
| Rate for Payer: Networks By Design Commercial |
$1.21
|
| Rate for Payer: Prime Health Services Commercial |
$1.58
|
|
|
DAPSONE 100 MG TABLET [2131]
|
Facility
|
OP
|
$1.86
|
|
|
Service Code
|
NDC 6498056603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.19
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cigna of CA HMO |
$1.30
|
| Rate for Payer: Cigna of CA PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.58
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: EPIC Health Plan Senior |
$0.74
|
| Rate for Payer: Galaxy Health WC |
$1.58
|
| Rate for Payer: Global Benefits Group Commercial |
$1.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$1.49
|
| Rate for Payer: Networks By Design Commercial |
$1.21
|
| Rate for Payer: Prime Health Services Commercial |
$1.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.93
|
| Rate for Payer: United Healthcare All Other HMO |
$0.93
|
| Rate for Payer: United Healthcare HMO Rider |
$0.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.58
|
| Rate for Payer: Vantage Medical Group Senior |
$1.58
|
|
|
DAPSONE 100 MG TABLET [2131]
|
Facility
|
OP
|
$1.45
|
|
|
Service Code
|
NDC 7095413610
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.93
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of CA HMO |
$1.01
|
| Rate for Payer: Cigna of CA PPO |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Senior |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Other HMO |
$0.73
|
| Rate for Payer: United Healthcare HMO Rider |
$0.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Vantage Medical Group Senior |
$1.23
|
|
|
DAPSONE 100 MG TABLET [2131]
|
Facility
|
IP
|
$1.45
|
|
|
Service Code
|
NDC 7095413610
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of CA HMO |
$1.01
|
| Rate for Payer: Cigna of CA PPO |
$1.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Senior |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.23
|
|
|
DAPSONE ORAL SUSPENSION COMPOUND 2 MG/ML [4080263]
|
Facility
|
IP
|
$2.37
|
|
|
Service Code
|
NDC 9994080263
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$1.82
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.66
|
| Rate for Payer: Cigna of CA PPO |
$1.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: EPIC Health Plan Senior |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.01
|
| Rate for Payer: Global Benefits Group Commercial |
$1.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.01
|
|
|
DAPSONE ORAL SUSPENSION COMPOUND 2 MG/ML [4080263]
|
Facility
|
OP
|
$2.37
|
|
|
Service Code
|
NDC 9994080263
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.66
|
| Rate for Payer: Cigna of CA PPO |
$1.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: EPIC Health Plan Senior |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.01
|
| Rate for Payer: Global Benefits Group Commercial |
$1.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.66
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.19
|
| Rate for Payer: United Healthcare All Other HMO |
$1.19
|
| Rate for Payer: United Healthcare HMO Rider |
$1.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.01
|
| Rate for Payer: Vantage Medical Group Senior |
$2.01
|
|
|
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$30.60 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$72.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of CA HMO |
$67.20
|
| Rate for Payer: Cigna of CA HMO |
$25.20
|
| Rate for Payer: Cigna of CA PPO |
$67.20
|
| Rate for Payer: Cigna of CA PPO |
$25.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$81.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$30.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$67.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: EPIC Health Plan Senior |
$38.40
|
| Rate for Payer: EPIC Health Plan Senior |
$14.40
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Galaxy Health WC |
$30.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Global Benefits Group Commercial |
$21.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$22.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$60.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$56.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$67.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$67.20
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: Networks By Design Commercial |
$48.00
|
| Rate for Payer: Networks By Design Commercial |
$18.00
|
| Rate for Payer: Prime Health Services Commercial |
$30.60
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$57.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$57.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.03
|
| Rate for Payer: United Healthcare All Other HMO |
$13.15
|
| Rate for Payer: United Healthcare All Other HMO |
$35.07
|
| Rate for Payer: United Healthcare HMO Rider |
$34.31
|
| Rate for Payer: United Healthcare HMO Rider |
$12.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$81.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.60
|
| Rate for Payer: Vantage Medical Group Senior |
$30.60
|
| Rate for Payer: Vantage Medical Group Senior |
$81.60
|
|
|
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.20 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Blue Shield of California Commercial |
$27.68
|
| Rate for Payer: Blue Shield of California Commercial |
$48.67
|
| Rate for Payer: Blue Shield of California Commercial |
$73.82
|
| Rate for Payer: Blue Shield of California Commercial |
$18.25
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of CA HMO |
$67.20
|
| Rate for Payer: Cigna of CA HMO |
$25.20
|
| Rate for Payer: Cigna of CA PPO |
$25.20
|
| Rate for Payer: Cigna of CA PPO |
$67.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$67.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: EPIC Health Plan Senior |
$14.40
|
| Rate for Payer: EPIC Health Plan Senior |
$38.40
|
| Rate for Payer: Galaxy Health WC |
$30.60
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Global Benefits Group Commercial |
$21.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$22.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$60.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$56.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.04
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: Networks By Design Commercial |
$48.00
|
| Rate for Payer: Networks By Design Commercial |
$18.00
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
| Rate for Payer: Prime Health Services Commercial |
$30.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.03
|
| Rate for Payer: United Healthcare All Other HMO |
$35.07
|
| Rate for Payer: United Healthcare All Other HMO |
$13.15
|
| Rate for Payer: United Healthcare HMO Rider |
$12.87
|
| Rate for Payer: United Healthcare HMO Rider |
$34.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.44
|
|
|
DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN [228045]
|
Facility
|
IP
|
$899.03
|
|
|
Service Code
|
HCPCS J9144
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$179.81 |
| Max. Negotiated Rate |
$764.18 |
| Rate for Payer: Cigna of CA PPO |
$629.32
|
| Rate for Payer: Adventist Health Commercial |
$179.81
|
| Rate for Payer: Blue Shield of California Commercial |
$455.81
|
| Rate for Payer: Blue Shield of California Commercial |
$691.35
|
| Rate for Payer: Cash Price |
$404.56
|
| Rate for Payer: Cigna of CA HMO |
$629.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$629.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$359.61
|
| Rate for Payer: EPIC Health Plan Senior |
$359.61
|
| Rate for Payer: Galaxy Health WC |
$764.18
|
| Rate for Payer: Global Benefits Group Commercial |
$539.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$570.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$530.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$215.77
|
| Rate for Payer: Multiplan Commercial |
$719.22
|
| Rate for Payer: Networks By Design Commercial |
$449.51
|
| Rate for Payer: Prime Health Services Commercial |
$764.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$337.41
|
| Rate for Payer: United Healthcare All Other HMO |
$328.42
|
| Rate for Payer: United Healthcare HMO Rider |
$321.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$294.43
|
|
|
DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN [228045]
|
Facility
|
OP
|
$899.03
|
|
|
Service Code
|
HCPCS J9144
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.05 |
| Max. Negotiated Rate |
$764.18 |
| Rate for Payer: Adventist Health Commercial |
$179.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$104.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$85.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$57.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$107.47
|
| Rate for Payer: Blue Shield of California Commercial |
$66.82
|
| Rate for Payer: Cash Price |
$404.56
|
| Rate for Payer: Cash Price |
$404.56
|
| Rate for Payer: Cigna of CA HMO |
$629.32
|
| Rate for Payer: Cigna of CA PPO |
$629.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$62.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$62.76
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$629.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$94.13
|
| Rate for Payer: EPIC Health Plan Senior |
$62.76
|
| Rate for Payer: Galaxy Health WC |
$764.18
|
| Rate for Payer: Global Benefits Group Commercial |
$539.42
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$93.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$57.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$57.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$570.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$113.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$79.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$215.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$71.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$76.45
|
| Rate for Payer: Multiplan Commercial |
$719.22
|
| Rate for Payer: Networks By Design Commercial |
$449.51
|
| Rate for Payer: Prime Health Services Commercial |
$764.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$539.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$539.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$337.41
|
| Rate for Payer: United Healthcare All Other HMO |
$328.42
|
| Rate for Payer: United Healthcare HMO Rider |
$321.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$294.43
|
| Rate for Payer: Upland Medical Group Pediatric |
$57.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$71.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$62.76
|
| Rate for Payer: Vantage Medical Group Senior |
$62.76
|
|
|
DARATUMUMAB-HYALURONIDASE-FIHJ (DARZALEX FASPRO) 1800 MG/30000 UNIT SQ INJECTION [40820601]
|
Facility
|
IP
|
$899.03
|
|
|
Service Code
|
HCPCS J9144
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$179.81 |
| Max. Negotiated Rate |
$764.18 |
| Rate for Payer: Adventist Health Commercial |
$179.81
|
| Rate for Payer: Blue Shield of California Commercial |
$455.81
|
| Rate for Payer: Blue Shield of California Commercial |
$691.35
|
| Rate for Payer: Cash Price |
$404.56
|
| Rate for Payer: Cigna of CA HMO |
$629.32
|
| Rate for Payer: Cigna of CA PPO |
$629.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$629.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$359.61
|
| Rate for Payer: EPIC Health Plan Senior |
$359.61
|
| Rate for Payer: Galaxy Health WC |
$764.18
|
| Rate for Payer: Global Benefits Group Commercial |
$539.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$570.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$530.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$215.77
|
| Rate for Payer: Multiplan Commercial |
$719.22
|
| Rate for Payer: Networks By Design Commercial |
$449.51
|
| Rate for Payer: Prime Health Services Commercial |
$764.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$337.41
|
| Rate for Payer: United Healthcare All Other HMO |
$328.42
|
| Rate for Payer: United Healthcare HMO Rider |
$321.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$294.43
|
|
|
DARATUMUMAB-HYALURONIDASE-FIHJ (DARZALEX FASPRO) 1800 MG/30000 UNIT SQ INJECTION [40820601]
|
Facility
|
OP
|
$899.03
|
|
|
Service Code
|
HCPCS J9144
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.05 |
| Max. Negotiated Rate |
$764.18 |
| Rate for Payer: Adventist Health Commercial |
$179.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$104.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$85.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$57.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$107.47
|
| Rate for Payer: Blue Shield of California Commercial |
$66.82
|
| Rate for Payer: Cash Price |
$404.56
|
| Rate for Payer: Cash Price |
$404.56
|
| Rate for Payer: Cigna of CA HMO |
$629.32
|
| Rate for Payer: Cigna of CA PPO |
$629.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$62.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$62.76
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$629.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$94.13
|
| Rate for Payer: EPIC Health Plan Senior |
$62.76
|
| Rate for Payer: Galaxy Health WC |
$764.18
|
| Rate for Payer: Global Benefits Group Commercial |
$539.42
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$93.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$57.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$57.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$570.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$113.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$79.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$215.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$71.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$76.45
|
| Rate for Payer: Multiplan Commercial |
$719.22
|
| Rate for Payer: Networks By Design Commercial |
$449.51
|
| Rate for Payer: Prime Health Services Commercial |
$764.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$539.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$539.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$337.41
|
| Rate for Payer: United Healthcare All Other HMO |
$328.42
|
| Rate for Payer: United Healthcare HMO Rider |
$321.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$294.43
|
| Rate for Payer: Upland Medical Group Pediatric |
$57.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$71.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$62.76
|
| Rate for Payer: Vantage Medical Group Senior |
$62.76
|
|
|
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE [108044]
|
Facility
|
IP
|
$1,857.60
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$371.52 |
| Max. Negotiated Rate |
$1,578.96 |
| Rate for Payer: Adventist Health Commercial |
$371.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1,428.49
|
| Rate for Payer: Blue Shield of California Commercial |
$941.80
|
| Rate for Payer: Cash Price |
$835.92
|
| Rate for Payer: Cigna of CA HMO |
$1,300.32
|
| Rate for Payer: Cigna of CA PPO |
$1,300.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,300.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$743.04
|
| Rate for Payer: EPIC Health Plan Senior |
$743.04
|
| Rate for Payer: Galaxy Health WC |
$1,578.96
|
| Rate for Payer: Global Benefits Group Commercial |
$1,114.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,179.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,095.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$445.82
|
| Rate for Payer: Multiplan Commercial |
$1,486.08
|
| Rate for Payer: Networks By Design Commercial |
$928.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,578.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$697.16
|
| Rate for Payer: United Healthcare All Other HMO |
$678.58
|
| Rate for Payer: United Healthcare HMO Rider |
$663.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$608.36
|
|
|
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE [108044]
|
Facility
|
OP
|
$1,857.60
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$1,578.96 |
| Rate for Payer: Adventist Health Commercial |
$371.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.52
|
| Rate for Payer: Blue Shield of California Commercial |
$9.29
|
| Rate for Payer: Cash Price |
$835.92
|
| Rate for Payer: Cash Price |
$835.92
|
| Rate for Payer: Cigna of CA HMO |
$1,300.32
|
| Rate for Payer: Cigna of CA PPO |
$1,300.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,300.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.82
|
| Rate for Payer: EPIC Health Plan Senior |
$3.21
|
| Rate for Payer: Galaxy Health WC |
$1,578.96
|
| Rate for Payer: Global Benefits Group Commercial |
$1,114.56
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,179.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$445.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.91
|
| Rate for Payer: Multiplan Commercial |
$1,486.08
|
| Rate for Payer: Networks By Design Commercial |
$928.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,578.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,114.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,114.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$697.16
|
| Rate for Payer: United Healthcare All Other HMO |
$678.58
|
| Rate for Payer: United Healthcare HMO Rider |
$663.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$608.36
|
| Rate for Payer: Upland Medical Group Pediatric |
$2.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.21
|
| Rate for Payer: Vantage Medical Group Senior |
$3.21
|
|
|
DARBEPOETIN ALFA 150 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE [108046]
|
Facility
|
IP
|
$4,644.00
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$928.80 |
| Max. Negotiated Rate |
$3,947.40 |
| Rate for Payer: Adventist Health Commercial |
$928.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2,354.51
|
| Rate for Payer: Blue Shield of California Commercial |
$3,571.24
|
| Rate for Payer: Cash Price |
$2,089.80
|
| Rate for Payer: Cigna of CA HMO |
$3,250.80
|
| Rate for Payer: Cigna of CA PPO |
$3,250.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,250.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,857.60
|
| Rate for Payer: EPIC Health Plan Senior |
$1,857.60
|
| Rate for Payer: Galaxy Health WC |
$3,947.40
|
| Rate for Payer: Global Benefits Group Commercial |
$2,786.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,948.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,739.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,114.56
|
| Rate for Payer: Multiplan Commercial |
$3,715.20
|
| Rate for Payer: Networks By Design Commercial |
$2,322.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,947.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,742.89
|
| Rate for Payer: United Healthcare All Other HMO |
$1,696.45
|
| Rate for Payer: United Healthcare HMO Rider |
$1,659.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,520.91
|
|
|
DARBEPOETIN ALFA 150 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE [108046]
|
Facility
|
OP
|
$4,644.00
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$3,947.40 |
| Rate for Payer: Adventist Health Commercial |
$928.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.52
|
| Rate for Payer: Blue Shield of California Commercial |
$9.29
|
| Rate for Payer: Cash Price |
$2,089.80
|
| Rate for Payer: Cash Price |
$2,089.80
|
| Rate for Payer: Cigna of CA HMO |
$3,250.80
|
| Rate for Payer: Cigna of CA PPO |
$3,250.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,250.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.82
|
| Rate for Payer: EPIC Health Plan Senior |
$3.21
|
| Rate for Payer: Galaxy Health WC |
$3,947.40
|
| Rate for Payer: Global Benefits Group Commercial |
$2,786.40
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,948.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,114.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.91
|
| Rate for Payer: Multiplan Commercial |
$3,715.20
|
| Rate for Payer: Networks By Design Commercial |
$2,322.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,947.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,786.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,786.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,742.89
|
| Rate for Payer: United Healthcare All Other HMO |
$1,696.45
|
| Rate for Payer: United Healthcare HMO Rider |
$1,659.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,520.91
|
| Rate for Payer: Upland Medical Group Pediatric |
$2.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.21
|
| Rate for Payer: Vantage Medical Group Senior |
$3.21
|
|
|
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [108047]
|
Facility
|
IP
|
$4,644.00
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$928.80 |
| Max. Negotiated Rate |
$3,947.40 |
| Rate for Payer: Adventist Health Commercial |
$928.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2,354.51
|
| Rate for Payer: Blue Shield of California Commercial |
$3,571.24
|
| Rate for Payer: Cash Price |
$2,089.80
|
| Rate for Payer: Cigna of CA HMO |
$3,250.80
|
| Rate for Payer: Cigna of CA PPO |
$3,250.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,250.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,857.60
|
| Rate for Payer: EPIC Health Plan Senior |
$1,857.60
|
| Rate for Payer: Galaxy Health WC |
$3,947.40
|
| Rate for Payer: Global Benefits Group Commercial |
$2,786.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,948.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,739.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,114.56
|
| Rate for Payer: Multiplan Commercial |
$3,715.20
|
| Rate for Payer: Networks By Design Commercial |
$2,322.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,947.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,742.89
|
| Rate for Payer: United Healthcare All Other HMO |
$1,696.45
|
| Rate for Payer: United Healthcare HMO Rider |
$1,659.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,520.91
|
|
|
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [108047]
|
Facility
|
OP
|
$4,644.00
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$3,947.40 |
| Rate for Payer: Adventist Health Commercial |
$928.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.52
|
| Rate for Payer: Blue Shield of California Commercial |
$9.29
|
| Rate for Payer: Cash Price |
$2,089.80
|
| Rate for Payer: Cash Price |
$2,089.80
|
| Rate for Payer: Cigna of CA HMO |
$3,250.80
|
| Rate for Payer: Cigna of CA PPO |
$3,250.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,250.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.82
|
| Rate for Payer: EPIC Health Plan Senior |
$3.21
|
| Rate for Payer: Galaxy Health WC |
$3,947.40
|
| Rate for Payer: Global Benefits Group Commercial |
$2,786.40
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,948.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,114.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.91
|
| Rate for Payer: Multiplan Commercial |
$3,715.20
|
| Rate for Payer: Networks By Design Commercial |
$2,322.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,947.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,786.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,786.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,742.89
|
| Rate for Payer: United Healthcare All Other HMO |
$1,696.45
|
| Rate for Payer: United Healthcare HMO Rider |
$1,659.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,520.91
|
| Rate for Payer: Upland Medical Group Pediatric |
$2.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.21
|
| Rate for Payer: Vantage Medical Group Senior |
$3.21
|
|
|
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE [108041]
|
Facility
|
OP
|
$552.86
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$469.93 |
| Rate for Payer: Adventist Health Commercial |
$110.57
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.52
|
| Rate for Payer: Blue Shield of California Commercial |
$9.29
|
| Rate for Payer: Cash Price |
$248.79
|
| Rate for Payer: Cash Price |
$248.79
|
| Rate for Payer: Cigna of CA HMO |
$387.00
|
| Rate for Payer: Cigna of CA PPO |
$387.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$387.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.82
|
| Rate for Payer: EPIC Health Plan Senior |
$3.21
|
| Rate for Payer: Galaxy Health WC |
$469.93
|
| Rate for Payer: Global Benefits Group Commercial |
$331.72
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$351.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.91
|
| Rate for Payer: Multiplan Commercial |
$442.29
|
| Rate for Payer: Networks By Design Commercial |
$276.43
|
| Rate for Payer: Prime Health Services Commercial |
$469.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$331.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$331.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$207.49
|
| Rate for Payer: United Healthcare All Other HMO |
$201.96
|
| Rate for Payer: United Healthcare HMO Rider |
$197.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$181.06
|
| Rate for Payer: Upland Medical Group Pediatric |
$2.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.21
|
| Rate for Payer: Vantage Medical Group Senior |
$3.21
|
|
|
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE [108041]
|
Facility
|
IP
|
$552.86
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.57 |
| Max. Negotiated Rate |
$469.93 |
| Rate for Payer: Adventist Health Commercial |
$110.57
|
| Rate for Payer: Blue Shield of California Commercial |
$280.30
|
| Rate for Payer: Blue Shield of California Commercial |
$425.15
|
| Rate for Payer: Cash Price |
$248.79
|
| Rate for Payer: Cigna of CA HMO |
$387.00
|
| Rate for Payer: Cigna of CA PPO |
$387.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$387.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$221.14
|
| Rate for Payer: EPIC Health Plan Senior |
$221.14
|
| Rate for Payer: Galaxy Health WC |
$469.93
|
| Rate for Payer: Global Benefits Group Commercial |
$331.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$351.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$326.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.69
|
| Rate for Payer: Multiplan Commercial |
$442.29
|
| Rate for Payer: Networks By Design Commercial |
$276.43
|
| Rate for Payer: Prime Health Services Commercial |
$469.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$207.49
|
| Rate for Payer: United Healthcare All Other HMO |
$201.96
|
| Rate for Payer: United Healthcare HMO Rider |
$197.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$181.06
|
|
|
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [108042]
|
Facility
|
IP
|
$928.80
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$185.76 |
| Max. Negotiated Rate |
$789.48 |
| Rate for Payer: Adventist Health Commercial |
$185.76
|
| Rate for Payer: Blue Shield of California Commercial |
$470.90
|
| Rate for Payer: Blue Shield of California Commercial |
$714.25
|
| Rate for Payer: Cash Price |
$417.96
|
| Rate for Payer: Cigna of CA HMO |
$650.16
|
| Rate for Payer: Cigna of CA PPO |
$650.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$650.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$371.52
|
| Rate for Payer: EPIC Health Plan Senior |
$371.52
|
| Rate for Payer: Galaxy Health WC |
$789.48
|
| Rate for Payer: Global Benefits Group Commercial |
$557.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$589.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$547.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$222.91
|
| Rate for Payer: Multiplan Commercial |
$743.04
|
| Rate for Payer: Networks By Design Commercial |
$464.40
|
| Rate for Payer: Prime Health Services Commercial |
$789.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$348.58
|
| Rate for Payer: United Healthcare All Other HMO |
$339.29
|
| Rate for Payer: United Healthcare HMO Rider |
$331.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$304.18
|
|
|
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [108042]
|
Facility
|
OP
|
$928.80
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$789.48 |
| Rate for Payer: Adventist Health Commercial |
$185.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.52
|
| Rate for Payer: Blue Shield of California Commercial |
$9.29
|
| Rate for Payer: Cash Price |
$417.96
|
| Rate for Payer: Cash Price |
$417.96
|
| Rate for Payer: Cigna of CA HMO |
$650.16
|
| Rate for Payer: Cigna of CA PPO |
$650.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$650.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.82
|
| Rate for Payer: EPIC Health Plan Senior |
$3.21
|
| Rate for Payer: Galaxy Health WC |
$789.48
|
| Rate for Payer: Global Benefits Group Commercial |
$557.28
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$589.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$222.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.91
|
| Rate for Payer: Multiplan Commercial |
$743.04
|
| Rate for Payer: Networks By Design Commercial |
$464.40
|
| Rate for Payer: Prime Health Services Commercial |
$789.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$557.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$557.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$348.58
|
| Rate for Payer: United Healthcare All Other HMO |
$339.29
|
| Rate for Payer: United Healthcare HMO Rider |
$331.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$304.18
|
| Rate for Payer: Upland Medical Group Pediatric |
$2.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.21
|
| Rate for Payer: Vantage Medical Group Senior |
$3.21
|
|
|
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE [108043]
|
Facility
|
IP
|
$1,857.60
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$371.52 |
| Max. Negotiated Rate |
$1,578.96 |
| Rate for Payer: Adventist Health Commercial |
$371.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1,428.49
|
| Rate for Payer: Blue Shield of California Commercial |
$941.80
|
| Rate for Payer: Cash Price |
$835.92
|
| Rate for Payer: Cigna of CA HMO |
$1,300.32
|
| Rate for Payer: Cigna of CA PPO |
$1,300.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,300.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$743.04
|
| Rate for Payer: EPIC Health Plan Senior |
$743.04
|
| Rate for Payer: Galaxy Health WC |
$1,578.96
|
| Rate for Payer: Global Benefits Group Commercial |
$1,114.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,179.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,095.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$445.82
|
| Rate for Payer: Multiplan Commercial |
$1,486.08
|
| Rate for Payer: Networks By Design Commercial |
$928.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,578.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$697.16
|
| Rate for Payer: United Healthcare All Other HMO |
$678.58
|
| Rate for Payer: United Healthcare HMO Rider |
$663.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$608.36
|
|
|
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE [108043]
|
Facility
|
OP
|
$1,857.60
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$1,578.96 |
| Rate for Payer: Adventist Health Commercial |
$371.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.52
|
| Rate for Payer: Blue Shield of California Commercial |
$9.29
|
| Rate for Payer: Cash Price |
$835.92
|
| Rate for Payer: Cash Price |
$835.92
|
| Rate for Payer: Cigna of CA HMO |
$1,300.32
|
| Rate for Payer: Cigna of CA PPO |
$1,300.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,300.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.82
|
| Rate for Payer: EPIC Health Plan Senior |
$3.21
|
| Rate for Payer: Galaxy Health WC |
$1,578.96
|
| Rate for Payer: Global Benefits Group Commercial |
$1,114.56
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,179.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$445.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.91
|
| Rate for Payer: Multiplan Commercial |
$1,486.08
|
| Rate for Payer: Networks By Design Commercial |
$928.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,578.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,114.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,114.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$697.16
|
| Rate for Payer: United Healthcare All Other HMO |
$678.58
|
| Rate for Payer: United Healthcare HMO Rider |
$663.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$608.36
|
| Rate for Payer: Upland Medical Group Pediatric |
$2.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.21
|
| Rate for Payer: Vantage Medical Group Senior |
$3.21
|
|
