|
DASATINIB 100 MG TABLET [92897]
|
Facility
IP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0852-22
|
| Hospital Charge Code |
1712498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$165.25 |
| Max. Negotiated Rate |
$585.26 |
| Rate for Payer: Blue Shield of California Commercial |
$490.24
|
| Rate for Payer: Blue Shield of California EPN |
$352.53
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Cigna of CA HMO |
$481.98
|
| Rate for Payer: Cigna of CA PPO |
$481.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$275.42
|
| Rate for Payer: Galaxy Health WC |
$585.26
|
| Rate for Payer: Global Benefits Group Commercial |
$413.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$459.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$165.25
|
| Rate for Payer: Multiplan Commercial |
$550.83
|
| Rate for Payer: Networks By Design Commercial |
$447.55
|
| Rate for Payer: Prime Health Services Commercial |
$585.26
|
|
|
DASATINIB 100 MG TABLET [92897]
|
Facility
OP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0852-22
|
| Hospital Charge Code |
1712498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$165.25 |
| Max. Negotiated Rate |
$585.26 |
| Rate for Payer: BCBS Transplant Transplant |
$413.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$451.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$585.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$378.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$378.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$410.23
|
| Rate for Payer: Blue Shield of California Commercial |
$507.45
|
| Rate for Payer: Blue Shield of California EPN |
$402.11
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Cigna of CA HMO |
$481.98
|
| Rate for Payer: Cigna of CA PPO |
$481.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$585.26
|
| Rate for Payer: Dignity Health Media |
$585.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$585.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$275.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$275.42
|
| Rate for Payer: Galaxy Health WC |
$585.26
|
| Rate for Payer: Global Benefits Group Commercial |
$413.12
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$516.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$459.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$165.25
|
| Rate for Payer: Multiplan Commercial |
$550.83
|
| Rate for Payer: Networks By Design Commercial |
$447.55
|
| Rate for Payer: Prime Health Services Commercial |
$585.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$413.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$413.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$413.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$344.27
|
| Rate for Payer: United Healthcare All Other HMO |
$344.27
|
| Rate for Payer: United Healthcare HMO Rider |
$344.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$344.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$585.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$585.26
|
| Rate for Payer: Vantage Medical Group Senior |
$585.26
|
|
|
DASATINIB 140 MG TABLET [108422]
|
Facility
OP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0857-22
|
| Hospital Charge Code |
1712499
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$165.25 |
| Max. Negotiated Rate |
$585.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$451.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$585.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$378.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$378.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$410.23
|
| Rate for Payer: BCBS Transplant Transplant |
$413.12
|
| Rate for Payer: Blue Shield of California Commercial |
$507.45
|
| Rate for Payer: Blue Shield of California EPN |
$402.11
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Cigna of CA HMO |
$481.98
|
| Rate for Payer: Cigna of CA PPO |
$481.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$585.26
|
| Rate for Payer: Dignity Health Media |
$585.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$585.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$275.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$275.42
|
| Rate for Payer: Galaxy Health WC |
$585.26
|
| Rate for Payer: Global Benefits Group Commercial |
$413.12
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$516.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$459.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$165.25
|
| Rate for Payer: Multiplan Commercial |
$550.83
|
| Rate for Payer: Networks By Design Commercial |
$447.55
|
| Rate for Payer: Prime Health Services Commercial |
$585.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$413.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$413.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$413.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$344.27
|
| Rate for Payer: United Healthcare All Other HMO |
$344.27
|
| Rate for Payer: United Healthcare HMO Rider |
$344.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$344.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$585.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$585.26
|
| Rate for Payer: Vantage Medical Group Senior |
$585.26
|
|
|
DASATINIB 140 MG TABLET [108422]
|
Facility
IP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0857-22
|
| Hospital Charge Code |
1712499
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$165.25 |
| Max. Negotiated Rate |
$585.26 |
| Rate for Payer: Blue Shield of California Commercial |
$490.24
|
| Rate for Payer: Blue Shield of California EPN |
$352.53
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Cigna of CA HMO |
$481.98
|
| Rate for Payer: Cigna of CA PPO |
$481.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$275.42
|
| Rate for Payer: Galaxy Health WC |
$585.26
|
| Rate for Payer: Global Benefits Group Commercial |
$413.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$459.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$165.25
|
| Rate for Payer: Multiplan Commercial |
$550.83
|
| Rate for Payer: Networks By Design Commercial |
$447.55
|
| Rate for Payer: Prime Health Services Commercial |
$585.26
|
|
|
DASATINIB 20 MG TABLET [76717]
|
Facility
IP
|
$191.01
|
|
|
Service Code
|
NDC 0003-0527-11
|
| Hospital Charge Code |
1711976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.84 |
| Max. Negotiated Rate |
$162.36 |
| Rate for Payer: Blue Shield of California Commercial |
$136.00
|
| Rate for Payer: Blue Shield of California EPN |
$97.80
|
| Rate for Payer: Cash Price |
$85.95
|
| Rate for Payer: Cigna of CA HMO |
$133.71
|
| Rate for Payer: Cigna of CA PPO |
$133.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.40
|
| Rate for Payer: Galaxy Health WC |
$162.36
|
| Rate for Payer: Global Benefits Group Commercial |
$114.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$127.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.84
|
| Rate for Payer: Multiplan Commercial |
$152.81
|
| Rate for Payer: Networks By Design Commercial |
$124.16
|
| Rate for Payer: Prime Health Services Commercial |
$162.36
|
|
|
DASATINIB 20 MG TABLET [76717]
|
Facility
OP
|
$191.01
|
|
|
Service Code
|
NDC 0003-0527-11
|
| Hospital Charge Code |
1711976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.84 |
| Max. Negotiated Rate |
$162.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$125.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$162.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$105.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$105.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$113.80
|
| Rate for Payer: BCBS Transplant Transplant |
$114.61
|
| Rate for Payer: Blue Shield of California Commercial |
$140.77
|
| Rate for Payer: Blue Shield of California EPN |
$111.55
|
| Rate for Payer: Cash Price |
$85.95
|
| Rate for Payer: Cigna of CA HMO |
$133.71
|
| Rate for Payer: Cigna of CA PPO |
$133.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.36
|
| Rate for Payer: Dignity Health Media |
$162.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$162.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$76.40
|
| Rate for Payer: Galaxy Health WC |
$162.36
|
| Rate for Payer: Global Benefits Group Commercial |
$114.61
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$143.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$127.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.84
|
| Rate for Payer: Multiplan Commercial |
$152.81
|
| Rate for Payer: Networks By Design Commercial |
$124.16
|
| Rate for Payer: Prime Health Services Commercial |
$162.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$114.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$114.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$114.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$95.50
|
| Rate for Payer: United Healthcare All Other HMO |
$95.50
|
| Rate for Payer: United Healthcare HMO Rider |
$95.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$95.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$162.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$162.36
|
| Rate for Payer: Vantage Medical Group Senior |
$162.36
|
|
|
DASATINIB 70 MG TABLET [76719]
|
Facility
IP
|
$382.03
|
|
|
Service Code
|
NDC 0003-0524-11
|
| Hospital Charge Code |
1711974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$91.69 |
| Max. Negotiated Rate |
$324.73 |
| Rate for Payer: Blue Shield of California Commercial |
$272.01
|
| Rate for Payer: Blue Shield of California EPN |
$195.60
|
| Rate for Payer: Cash Price |
$171.91
|
| Rate for Payer: Cigna of CA HMO |
$267.42
|
| Rate for Payer: Cigna of CA PPO |
$267.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.81
|
| Rate for Payer: Galaxy Health WC |
$324.73
|
| Rate for Payer: Global Benefits Group Commercial |
$229.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$254.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$145.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.69
|
| Rate for Payer: Multiplan Commercial |
$305.62
|
| Rate for Payer: Networks By Design Commercial |
$248.32
|
| Rate for Payer: Prime Health Services Commercial |
$324.73
|
|
|
DASATINIB 70 MG TABLET [76719]
|
Facility
OP
|
$382.03
|
|
|
Service Code
|
NDC 0003-0524-11
|
| Hospital Charge Code |
1711974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$91.69 |
| Max. Negotiated Rate |
$324.73 |
| Rate for Payer: Galaxy Health WC |
$324.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$250.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$324.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$210.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$210.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$227.61
|
| Rate for Payer: BCBS Transplant Transplant |
$229.22
|
| Rate for Payer: Blue Shield of California Commercial |
$281.56
|
| Rate for Payer: Blue Shield of California EPN |
$223.11
|
| Rate for Payer: Cash Price |
$171.91
|
| Rate for Payer: Cigna of CA HMO |
$267.42
|
| Rate for Payer: Cigna of CA PPO |
$267.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$324.73
|
| Rate for Payer: Dignity Health Media |
$324.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$324.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$152.81
|
| Rate for Payer: Global Benefits Group Commercial |
$229.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$286.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$254.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$145.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.69
|
| Rate for Payer: Multiplan Commercial |
$305.62
|
| Rate for Payer: Networks By Design Commercial |
$248.32
|
| Rate for Payer: Prime Health Services Commercial |
$324.73
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$229.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$229.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$229.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$191.02
|
| Rate for Payer: United Healthcare All Other HMO |
$191.02
|
| Rate for Payer: United Healthcare HMO Rider |
$191.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$191.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$324.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$324.73
|
| Rate for Payer: Vantage Medical Group Senior |
$324.73
|
|
|
DASATINIB 80 MG TABLET [108421]
|
Facility
OP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0855-22
|
| Hospital Charge Code |
1712500
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$165.25 |
| Max. Negotiated Rate |
$585.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$451.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$585.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$378.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$378.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$410.23
|
| Rate for Payer: BCBS Transplant Transplant |
$413.12
|
| Rate for Payer: Blue Shield of California Commercial |
$507.45
|
| Rate for Payer: Blue Shield of California EPN |
$402.11
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Cigna of CA HMO |
$481.98
|
| Rate for Payer: Cigna of CA PPO |
$481.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$585.26
|
| Rate for Payer: Dignity Health Media |
$585.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$585.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$275.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$275.42
|
| Rate for Payer: Galaxy Health WC |
$585.26
|
| Rate for Payer: Global Benefits Group Commercial |
$413.12
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$516.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$459.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$165.25
|
| Rate for Payer: Multiplan Commercial |
$550.83
|
| Rate for Payer: Networks By Design Commercial |
$447.55
|
| Rate for Payer: Prime Health Services Commercial |
$585.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$413.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$413.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$413.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$344.27
|
| Rate for Payer: United Healthcare All Other HMO |
$344.27
|
| Rate for Payer: United Healthcare HMO Rider |
$344.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$344.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$585.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$585.26
|
| Rate for Payer: Vantage Medical Group Senior |
$585.26
|
|
|
DASATINIB 80 MG TABLET [108421]
|
Facility
IP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0855-22
|
| Hospital Charge Code |
1712500
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$165.25 |
| Max. Negotiated Rate |
$585.26 |
| Rate for Payer: Blue Shield of California Commercial |
$490.24
|
| Rate for Payer: Blue Shield of California EPN |
$352.53
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Cigna of CA HMO |
$481.98
|
| Rate for Payer: Cigna of CA PPO |
$481.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$275.42
|
| Rate for Payer: Galaxy Health WC |
$585.26
|
| Rate for Payer: Global Benefits Group Commercial |
$413.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$459.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$165.25
|
| Rate for Payer: Multiplan Commercial |
$550.83
|
| Rate for Payer: Networks By Design Commercial |
$447.55
|
| Rate for Payer: Prime Health Services Commercial |
$585.26
|
|
|
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION [219514]
|
Facility
OP
|
$11,772.00
|
|
|
Service Code
|
CPT J9153
|
| Hospital Charge Code |
ERX219514
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$230.96 |
| Max. Negotiated Rate |
$10,006.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$456.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$289.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$254.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$254.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$386.69
|
| Rate for Payer: BCBS Transplant Transplant |
$7,063.20
|
| Rate for Payer: Blue Shield of California Commercial |
$8,675.96
|
| Rate for Payer: Blue Shield of California EPN |
$230.96
|
| Rate for Payer: Cash Price |
$5,297.40
|
| Rate for Payer: Cash Price |
$5,297.40
|
| Rate for Payer: Cigna of CA HMO |
$8,240.40
|
| Rate for Payer: Cigna of CA PPO |
$8,240.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$347.65
|
| Rate for Payer: Dignity Health Media |
$231.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$254.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$312.88
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$231.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$231.76
|
| Rate for Payer: Galaxy Health WC |
$10,006.20
|
| Rate for Payer: Global Benefits Group Commercial |
$7,063.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8,829.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$380.09
|
| Rate for Payer: Heritage Provider Network Transplant |
$380.09
|
| Rate for Payer: IEHP Medi-Cal |
$375.46
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$375.46
|
| Rate for Payer: IEHP Medicare Advantage |
$231.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,851.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$448.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$231.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,825.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$292.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$310.56
|
| Rate for Payer: Multiplan Commercial |
$9,417.60
|
| Rate for Payer: Networks By Design Commercial |
$5,886.00
|
| Rate for Payer: Prime Health Services Commercial |
$10,006.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7,063.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7,063.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,886.00
|
| Rate for Payer: United Healthcare All Other HMO |
$5,886.00
|
| Rate for Payer: United Healthcare HMO Rider |
$5,886.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5,886.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$347.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$254.94
|
| Rate for Payer: Vantage Medical Group Senior |
$231.76
|
|
|
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION [219514]
|
Facility
IP
|
$11,772.00
|
|
|
Service Code
|
CPT J9153
|
| Hospital Charge Code |
ERX219514
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,825.28 |
| Max. Negotiated Rate |
$10,006.20 |
| Rate for Payer: Blue Shield of California Commercial |
$8,381.66
|
| Rate for Payer: Blue Shield of California EPN |
$6,027.26
|
| Rate for Payer: Cash Price |
$5,297.40
|
| Rate for Payer: Cigna of CA HMO |
$8,240.40
|
| Rate for Payer: Cigna of CA PPO |
$8,240.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,708.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,708.80
|
| Rate for Payer: Galaxy Health WC |
$10,006.20
|
| Rate for Payer: Global Benefits Group Commercial |
$7,063.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,851.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,485.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,825.28
|
| Rate for Payer: Multiplan Commercial |
$9,417.60
|
| Rate for Payer: Networks By Design Commercial |
$5,886.00
|
| Rate for Payer: Prime Health Services Commercial |
$10,006.20
|
|
|
DAUNORUBICIN 5 MG/ML INTRAVENOUS SOLUTION [22661]
|
Facility
IP
|
$39.34
|
|
|
Service Code
|
CPT J9150
|
| Hospital Charge Code |
1755125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$33.44 |
| Rate for Payer: Blue Shield of California Commercial |
$28.01
|
| Rate for Payer: Blue Shield of California EPN |
$20.14
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna of CA HMO |
$27.54
|
| Rate for Payer: Cigna of CA PPO |
$27.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.74
|
| Rate for Payer: Galaxy Health WC |
$33.44
|
| Rate for Payer: Global Benefits Group Commercial |
$23.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.44
|
| Rate for Payer: Multiplan Commercial |
$31.47
|
| Rate for Payer: Networks By Design Commercial |
$19.67
|
| Rate for Payer: Prime Health Services Commercial |
$33.44
|
|
|
DAUNORUBICIN 5 MG/ML INTRAVENOUS SOLUTION [22661]
|
Facility
OP
|
$39.34
|
|
|
Service Code
|
CPT J9150
|
| Hospital Charge Code |
1755125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$166.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$70.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$44.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$39.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$39.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$166.34
|
| Rate for Payer: BCBS Transplant Transplant |
$23.60
|
| Rate for Payer: Blue Shield of California Commercial |
$28.99
|
| Rate for Payer: Blue Shield of California EPN |
$80.48
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna of CA HMO |
$27.54
|
| Rate for Payer: Cigna of CA PPO |
$27.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$53.51
|
| Rate for Payer: Dignity Health Media |
$35.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.16
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$35.67
|
| Rate for Payer: EPIC Health Plan Transplant |
$35.67
|
| Rate for Payer: Galaxy Health WC |
$33.44
|
| Rate for Payer: Global Benefits Group Commercial |
$23.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$29.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.50
|
| Rate for Payer: Heritage Provider Network Transplant |
$58.50
|
| Rate for Payer: IEHP Medi-Cal |
$57.79
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$57.79
|
| Rate for Payer: IEHP Medicare Advantage |
$35.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$44.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$47.80
|
| Rate for Payer: Multiplan Commercial |
$31.47
|
| Rate for Payer: Networks By Design Commercial |
$19.67
|
| Rate for Payer: Prime Health Services Commercial |
$33.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.67
|
| Rate for Payer: United Healthcare All Other HMO |
$19.67
|
| Rate for Payer: United Healthcare HMO Rider |
$19.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$53.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.24
|
| Rate for Payer: Vantage Medical Group Senior |
$35.67
|
|
|
Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less
|
Facility
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 11044
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$7,385.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7,385.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,025.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,938.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Dignity Health Media |
$2,025.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,228.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,734.68
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,025.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,025.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,322.13
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,322.13
|
| Rate for Payer: IEHP Medi-Cal |
$3,281.62
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$3,281.62
|
| Rate for Payer: IEHP Medicare Advantage |
$2,025.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$384.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,025.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,552.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,714.42
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$225.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$225.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.69
|
|
|
Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone
|
Facility
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 11012
|
| Min. Negotiated Rate |
$731.42 |
| Max. Negotiated Rate |
$7,385.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7,385.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5,325.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,905.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,550.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,938.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,325.39
|
| Rate for Payer: Dignity Health Media |
$3,550.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,905.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,792.85
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3,550.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,550.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,822.43
|
| Rate for Payer: Heritage Provider Network Transplant |
$5,822.43
|
| Rate for Payer: IEHP Medi-Cal |
$5,751.42
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$5,751.42
|
| Rate for Payer: IEHP Medicare Advantage |
$3,550.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$731.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,550.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,473.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,757.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,325.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,905.29
|
| Rate for Payer: Vantage Medical Group Senior |
$3,550.26
|
|
|
DECITABINE 35 MG-CEDAZURIDINE 100 MG TABLET [228955]
|
Facility
IP
|
$1,943.95
|
|
|
Service Code
|
NDC 64842-0727-9
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$466.55 |
| Max. Negotiated Rate |
$1,652.36 |
| Rate for Payer: Blue Shield of California Commercial |
$1,384.09
|
| Rate for Payer: Blue Shield of California EPN |
$995.30
|
| Rate for Payer: Cash Price |
$874.78
|
| Rate for Payer: Cigna of CA HMO |
$1,360.76
|
| Rate for Payer: Cigna of CA PPO |
$1,360.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$777.58
|
| Rate for Payer: Galaxy Health WC |
$1,652.36
|
| Rate for Payer: Global Benefits Group Commercial |
$1,166.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,296.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$740.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$466.55
|
| Rate for Payer: Multiplan Commercial |
$1,555.16
|
| Rate for Payer: Networks By Design Commercial |
$1,263.57
|
| Rate for Payer: Prime Health Services Commercial |
$1,652.36
|
|
|
DECITABINE 35 MG-CEDAZURIDINE 100 MG TABLET [228955]
|
Facility
OP
|
$1,943.95
|
|
|
Service Code
|
NDC 64842-0727-9
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$466.55 |
| Max. Negotiated Rate |
$1,652.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,275.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,652.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,069.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,069.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,158.21
|
| Rate for Payer: BCBS Transplant Transplant |
$1,166.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1,432.69
|
| Rate for Payer: Blue Shield of California EPN |
$1,135.27
|
| Rate for Payer: Cash Price |
$874.78
|
| Rate for Payer: Cigna of CA HMO |
$1,360.76
|
| Rate for Payer: Cigna of CA PPO |
$1,360.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,652.36
|
| Rate for Payer: Dignity Health Media |
$1,652.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,652.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$777.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$777.58
|
| Rate for Payer: Galaxy Health WC |
$1,652.36
|
| Rate for Payer: Global Benefits Group Commercial |
$1,166.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,457.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,296.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$740.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$466.55
|
| Rate for Payer: Multiplan Commercial |
$1,555.16
|
| Rate for Payer: Networks By Design Commercial |
$1,263.57
|
| Rate for Payer: Prime Health Services Commercial |
$1,652.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1,166.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,166.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,166.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$971.98
|
| Rate for Payer: United Healthcare All Other HMO |
$971.98
|
| Rate for Payer: United Healthcare HMO Rider |
$971.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$971.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,652.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,652.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1,652.36
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
IP
|
$120.00
|
|
|
Service Code
|
CPT J0894
|
| Hospital Charge Code |
1755761
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.80 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: Blue Shield of California Commercial |
$85.44
|
| Rate for Payer: Blue Shield of California Commercial |
$170.88
|
| Rate for Payer: Blue Shield of California Commercial |
$169.17
|
| Rate for Payer: Blue Shield of California Commercial |
$512.64
|
| Rate for Payer: Blue Shield of California EPN |
$61.44
|
| Rate for Payer: Blue Shield of California EPN |
$122.88
|
| Rate for Payer: Blue Shield of California EPN |
$368.64
|
| Rate for Payer: Blue Shield of California EPN |
$121.65
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cigna of CA HMO |
$504.00
|
| Rate for Payer: Cigna of CA HMO |
$166.32
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA HMO |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$166.32
|
| Rate for Payer: Cigna of CA PPO |
$504.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$288.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$95.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$288.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$612.00
|
| Rate for Payer: Galaxy Health WC |
$201.96
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Global Benefits Group Commercial |
$432.00
|
| Rate for Payer: Global Benefits Group Commercial |
$142.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$158.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$480.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$274.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.60
|
| Rate for Payer: Multiplan Commercial |
$190.08
|
| Rate for Payer: Multiplan Commercial |
$576.00
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Networks By Design Commercial |
$118.80
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Networks By Design Commercial |
$360.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
| Rate for Payer: Prime Health Services Commercial |
$201.96
|
| Rate for Payer: Prime Health Services Commercial |
$612.00
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
OP
|
$237.60
|
|
|
Service Code
|
CPT J0894
|
| Hospital Charge Code |
1755761
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$201.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$201.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$612.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$396.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$130.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$132.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$130.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$66.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$396.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.33
|
| Rate for Payer: BCBS Transplant Transplant |
$432.00
|
| Rate for Payer: BCBS Transplant Transplant |
$72.00
|
| Rate for Payer: BCBS Transplant Transplant |
$144.00
|
| Rate for Payer: BCBS Transplant Transplant |
$142.56
|
| Rate for Payer: Blue Shield of California Commercial |
$175.11
|
| Rate for Payer: Blue Shield of California Commercial |
$176.88
|
| Rate for Payer: Blue Shield of California Commercial |
$88.44
|
| Rate for Payer: Blue Shield of California Commercial |
$530.64
|
| Rate for Payer: Blue Shield of California EPN |
$15.60
|
| Rate for Payer: Blue Shield of California EPN |
$15.60
|
| Rate for Payer: Blue Shield of California EPN |
$15.60
|
| Rate for Payer: Blue Shield of California EPN |
$15.60
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna of CA HMO |
$84.00
|
| Rate for Payer: Cigna of CA HMO |
$504.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA HMO |
$166.32
|
| Rate for Payer: Cigna of CA PPO |
$504.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$166.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$201.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$612.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Media |
$612.00
|
| Rate for Payer: Dignity Health Media |
$204.00
|
| Rate for Payer: Dignity Health Media |
$102.00
|
| Rate for Payer: Dignity Health Media |
$201.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$201.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$612.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$288.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$95.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$288.00
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Galaxy Health WC |
$201.96
|
| Rate for Payer: Galaxy Health WC |
$612.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Global Benefits Group Commercial |
$142.56
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Global Benefits Group Commercial |
$432.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$540.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$90.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$180.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$178.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$480.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$158.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.02
|
| Rate for Payer: Multiplan Commercial |
$576.00
|
| Rate for Payer: Multiplan Commercial |
$190.08
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Networks By Design Commercial |
$360.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Networks By Design Commercial |
$118.80
|
| Rate for Payer: Prime Health Services Commercial |
$201.96
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: Prime Health Services Commercial |
$612.00
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$144.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$142.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$72.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$432.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$72.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$432.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$144.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$142.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$118.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$360.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Other HMO |
$360.00
|
| Rate for Payer: United Healthcare All Other HMO |
$60.00
|
| Rate for Payer: United Healthcare All Other HMO |
$118.80
|
| Rate for Payer: United Healthcare All Other HMO |
$120.00
|
| Rate for Payer: United Healthcare HMO Rider |
$118.80
|
| Rate for Payer: United Healthcare HMO Rider |
$360.00
|
| Rate for Payer: United Healthcare HMO Rider |
$120.00
|
| Rate for Payer: United Healthcare HMO Rider |
$60.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$120.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$118.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$360.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$201.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$612.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$201.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$612.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
| Rate for Payer: Vantage Medical Group Senior |
$201.96
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$612.00
|
|
|
DEFERASIROX 180 MG TABLET [206427]
|
Facility
IP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0655-15
|
| Hospital Charge Code |
ERX206427
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.07 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Blue Shield of California Commercial |
$83.27
|
| Rate for Payer: Blue Shield of California EPN |
$59.88
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Cigna of CA HMO |
$81.86
|
| Rate for Payer: Cigna of CA PPO |
$81.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$99.41
|
| Rate for Payer: Global Benefits Group Commercial |
$70.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.07
|
| Rate for Payer: Multiplan Commercial |
$93.56
|
| Rate for Payer: Networks By Design Commercial |
$76.02
|
| Rate for Payer: Prime Health Services Commercial |
$99.41
|
|
|
DEFERASIROX 180 MG TABLET [206427]
|
Facility
OP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0655-15
|
| Hospital Charge Code |
ERX206427
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.07 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$76.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$99.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$64.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$64.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$69.68
|
| Rate for Payer: BCBS Transplant Transplant |
$70.17
|
| Rate for Payer: Blue Shield of California Commercial |
$86.19
|
| Rate for Payer: Blue Shield of California EPN |
$68.30
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Cigna of CA HMO |
$81.86
|
| Rate for Payer: Cigna of CA PPO |
$81.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.41
|
| Rate for Payer: Dignity Health Media |
$99.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$99.41
|
| Rate for Payer: Global Benefits Group Commercial |
$70.17
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$87.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.07
|
| Rate for Payer: Multiplan Commercial |
$93.56
|
| Rate for Payer: Networks By Design Commercial |
$76.02
|
| Rate for Payer: Prime Health Services Commercial |
$99.41
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$70.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$58.48
|
| Rate for Payer: United Healthcare All Other HMO |
$58.48
|
| Rate for Payer: United Healthcare HMO Rider |
$58.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$58.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$99.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.41
|
| Rate for Payer: Vantage Medical Group Senior |
$99.41
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
OP
|
$60.08
|
|
|
Service Code
|
NDC 45963-455-30
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.42 |
| Max. Negotiated Rate |
$51.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$39.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$51.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$33.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.80
|
| Rate for Payer: BCBS Transplant Transplant |
$36.05
|
| Rate for Payer: Blue Shield of California Commercial |
$44.28
|
| Rate for Payer: Blue Shield of California EPN |
$35.09
|
| Rate for Payer: Cash Price |
$27.04
|
| Rate for Payer: Cigna of CA HMO |
$42.06
|
| Rate for Payer: Cigna of CA PPO |
$42.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.07
|
| Rate for Payer: Dignity Health Media |
$51.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.03
|
| Rate for Payer: Galaxy Health WC |
$51.07
|
| Rate for Payer: Global Benefits Group Commercial |
$36.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$45.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.42
|
| Rate for Payer: Multiplan Commercial |
$48.06
|
| Rate for Payer: Networks By Design Commercial |
$39.05
|
| Rate for Payer: Prime Health Services Commercial |
$51.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$36.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$36.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$36.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.04
|
| Rate for Payer: United Healthcare All Other HMO |
$30.04
|
| Rate for Payer: United Healthcare HMO Rider |
$30.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.07
|
| Rate for Payer: Vantage Medical Group Senior |
$51.07
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
IP
|
$60.08
|
|
|
Service Code
|
NDC 45963-455-30
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.42 |
| Max. Negotiated Rate |
$51.07 |
| Rate for Payer: Blue Shield of California Commercial |
$42.78
|
| Rate for Payer: Blue Shield of California EPN |
$30.76
|
| Rate for Payer: Cash Price |
$27.04
|
| Rate for Payer: Cigna of CA HMO |
$42.06
|
| Rate for Payer: Cigna of CA PPO |
$42.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.03
|
| Rate for Payer: Galaxy Health WC |
$51.07
|
| Rate for Payer: Global Benefits Group Commercial |
$36.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.42
|
| Rate for Payer: Multiplan Commercial |
$48.06
|
| Rate for Payer: Networks By Design Commercial |
$39.05
|
| Rate for Payer: Prime Health Services Commercial |
$51.07
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
OP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0469-15
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.07 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$76.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$99.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$64.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$64.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$69.68
|
| Rate for Payer: BCBS Transplant Transplant |
$70.17
|
| Rate for Payer: Blue Shield of California Commercial |
$86.19
|
| Rate for Payer: Blue Shield of California EPN |
$68.30
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Cigna of CA HMO |
$81.86
|
| Rate for Payer: Cigna of CA PPO |
$81.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.41
|
| Rate for Payer: Dignity Health Media |
$99.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$99.41
|
| Rate for Payer: Global Benefits Group Commercial |
$70.17
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$87.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.07
|
| Rate for Payer: Multiplan Commercial |
$93.56
|
| Rate for Payer: Networks By Design Commercial |
$76.02
|
| Rate for Payer: Prime Health Services Commercial |
$99.41
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$70.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$58.48
|
| Rate for Payer: United Healthcare All Other HMO |
$58.48
|
| Rate for Payer: United Healthcare HMO Rider |
$58.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$58.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$99.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.41
|
| Rate for Payer: Vantage Medical Group Senior |
$99.41
|
|
