|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
1710987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.83 |
| Max. Negotiated Rate |
$197.74 |
| Rate for Payer: Blue Shield of California Commercial |
$165.63
|
| Rate for Payer: Blue Shield of California EPN |
$119.11
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Cigna of CA HMO |
$162.84
|
| Rate for Payer: Cigna of CA PPO |
$162.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.05
|
| Rate for Payer: Galaxy Health WC |
$197.74
|
| Rate for Payer: Global Benefits Group Commercial |
$139.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$155.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.83
|
| Rate for Payer: Multiplan Commercial |
$186.10
|
| Rate for Payer: Networks By Design Commercial |
$151.21
|
| Rate for Payer: Prime Health Services Commercial |
$197.74
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
1710987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.83 |
| Max. Negotiated Rate |
$197.74 |
| Rate for Payer: Blue Shield of California Commercial |
$165.63
|
| Rate for Payer: Blue Shield of California EPN |
$119.11
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Cigna of CA HMO |
$162.84
|
| Rate for Payer: Cigna of CA PPO |
$162.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.05
|
| Rate for Payer: Galaxy Health WC |
$197.74
|
| Rate for Payer: Global Benefits Group Commercial |
$139.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$155.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.83
|
| Rate for Payer: Multiplan Commercial |
$186.10
|
| Rate for Payer: Networks By Design Commercial |
$151.21
|
| Rate for Payer: Prime Health Services Commercial |
$197.74
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
OP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
ERX40831875
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.83 |
| Max. Negotiated Rate |
$197.74 |
| Rate for Payer: Aetna of CA HMO/PPO |
$152.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$197.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$127.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$127.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.60
|
| Rate for Payer: Blue Distinction Transplant |
$139.58
|
| Rate for Payer: Blue Shield of California Commercial |
$171.45
|
| Rate for Payer: Blue Shield of California EPN |
$135.86
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Cigna of CA HMO |
$162.84
|
| Rate for Payer: Cigna of CA PPO |
$162.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$197.74
|
| Rate for Payer: Dignity Health Media |
$197.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$197.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$93.05
|
| Rate for Payer: Galaxy Health WC |
$197.74
|
| Rate for Payer: Global Benefits Group Commercial |
$139.58
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$174.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$155.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.83
|
| Rate for Payer: Multiplan Commercial |
$186.10
|
| Rate for Payer: Networks By Design Commercial |
$151.21
|
| Rate for Payer: Prime Health Services Commercial |
$197.74
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$139.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$139.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$116.32
|
| Rate for Payer: United Healthcare All Other HMO |
$116.32
|
| Rate for Payer: United Healthcare HMO Rider |
$116.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$116.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$197.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$197.74
|
| Rate for Payer: Vantage Medical Group Senior |
$197.74
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
IP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
ERX40831875
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.83 |
| Max. Negotiated Rate |
$197.74 |
| Rate for Payer: Blue Shield of California Commercial |
$165.63
|
| Rate for Payer: Blue Shield of California EPN |
$119.11
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Cigna of CA HMO |
$162.84
|
| Rate for Payer: Cigna of CA PPO |
$162.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.05
|
| Rate for Payer: Galaxy Health WC |
$197.74
|
| Rate for Payer: Global Benefits Group Commercial |
$139.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$155.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.83
|
| Rate for Payer: Multiplan Commercial |
$186.10
|
| Rate for Payer: Networks By Design Commercial |
$151.21
|
| Rate for Payer: Prime Health Services Commercial |
$197.74
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
OP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
ERX40831875
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.83 |
| Max. Negotiated Rate |
$197.74 |
| Rate for Payer: Aetna of CA HMO/PPO |
$152.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$197.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$127.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$127.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.60
|
| Rate for Payer: Blue Distinction Transplant |
$139.58
|
| Rate for Payer: Blue Shield of California Commercial |
$171.45
|
| Rate for Payer: Blue Shield of California EPN |
$135.86
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Cigna of CA HMO |
$162.84
|
| Rate for Payer: Cigna of CA PPO |
$162.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$197.74
|
| Rate for Payer: Dignity Health Media |
$197.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$197.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$93.05
|
| Rate for Payer: Galaxy Health WC |
$197.74
|
| Rate for Payer: Global Benefits Group Commercial |
$139.58
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$174.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$155.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.83
|
| Rate for Payer: Multiplan Commercial |
$186.10
|
| Rate for Payer: Networks By Design Commercial |
$151.21
|
| Rate for Payer: Prime Health Services Commercial |
$197.74
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$139.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$139.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$116.32
|
| Rate for Payer: United Healthcare All Other HMO |
$116.32
|
| Rate for Payer: United Healthcare HMO Rider |
$116.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$116.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$197.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$197.74
|
| Rate for Payer: Vantage Medical Group Senior |
$197.74
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
IP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
ERX40831875
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.83 |
| Max. Negotiated Rate |
$197.74 |
| Rate for Payer: Blue Shield of California Commercial |
$165.63
|
| Rate for Payer: Blue Shield of California EPN |
$119.11
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Cigna of CA HMO |
$162.84
|
| Rate for Payer: Cigna of CA PPO |
$162.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.05
|
| Rate for Payer: Galaxy Health WC |
$197.74
|
| Rate for Payer: Global Benefits Group Commercial |
$139.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$155.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.83
|
| Rate for Payer: Multiplan Commercial |
$186.10
|
| Rate for Payer: Networks By Design Commercial |
$151.21
|
| Rate for Payer: Prime Health Services Commercial |
$197.74
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
|
IP
|
$16.44
|
|
|
Service Code
|
NDC 9940-8318-76
|
| Hospital Charge Code |
NDC40831876
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$13.97 |
| Rate for Payer: Blue Shield of California Commercial |
$11.71
|
| Rate for Payer: Blue Shield of California EPN |
$8.42
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: Cigna of CA HMO |
$11.51
|
| Rate for Payer: Cigna of CA PPO |
$11.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.58
|
| Rate for Payer: Galaxy Health WC |
$13.97
|
| Rate for Payer: Global Benefits Group Commercial |
$9.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.95
|
| Rate for Payer: Multiplan Commercial |
$13.15
|
| Rate for Payer: Networks By Design Commercial |
$10.69
|
| Rate for Payer: Prime Health Services Commercial |
$13.97
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
|
OP
|
$16.44
|
|
|
Service Code
|
NDC 9940-8318-76
|
| Hospital Charge Code |
NDC40831876
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$13.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$10.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.79
|
| Rate for Payer: Blue Distinction Transplant |
$9.86
|
| Rate for Payer: Blue Shield of California Commercial |
$12.12
|
| Rate for Payer: Blue Shield of California EPN |
$9.60
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: Cigna of CA HMO |
$11.51
|
| Rate for Payer: Cigna of CA PPO |
$11.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.97
|
| Rate for Payer: Dignity Health Media |
$13.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.58
|
| Rate for Payer: Galaxy Health WC |
$13.97
|
| Rate for Payer: Global Benefits Group Commercial |
$9.86
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$12.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.95
|
| Rate for Payer: Multiplan Commercial |
$13.15
|
| Rate for Payer: Networks By Design Commercial |
$10.69
|
| Rate for Payer: Prime Health Services Commercial |
$13.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.22
|
| Rate for Payer: United Healthcare All Other HMO |
$8.22
|
| Rate for Payer: United Healthcare HMO Rider |
$8.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.97
|
| Rate for Payer: Vantage Medical Group Senior |
$13.97
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
|
OP
|
$194.83
|
|
|
Service Code
|
NDC 0069-0135-01
|
| Hospital Charge Code |
ERX197246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.76 |
| Max. Negotiated Rate |
$165.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$127.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$165.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$107.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$107.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$116.08
|
| Rate for Payer: Blue Distinction Transplant |
$116.90
|
| Rate for Payer: Blue Shield of California Commercial |
$143.59
|
| Rate for Payer: Blue Shield of California EPN |
$113.78
|
| Rate for Payer: Cash Price |
$87.67
|
| Rate for Payer: Cigna of CA HMO |
$136.38
|
| Rate for Payer: Cigna of CA PPO |
$136.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$165.61
|
| Rate for Payer: Dignity Health Media |
$165.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$165.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$77.93
|
| Rate for Payer: EPIC Health Plan Transplant |
$77.93
|
| Rate for Payer: Galaxy Health WC |
$165.61
|
| Rate for Payer: Global Benefits Group Commercial |
$116.90
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$146.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$129.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$74.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.76
|
| Rate for Payer: Multiplan Commercial |
$155.86
|
| Rate for Payer: Networks By Design Commercial |
$126.64
|
| Rate for Payer: Prime Health Services Commercial |
$165.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$116.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$116.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$97.42
|
| Rate for Payer: United Healthcare All Other HMO |
$97.42
|
| Rate for Payer: United Healthcare HMO Rider |
$97.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$97.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$165.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$165.61
|
| Rate for Payer: Vantage Medical Group Senior |
$165.61
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
|
IP
|
$194.83
|
|
|
Service Code
|
NDC 0069-0135-01
|
| Hospital Charge Code |
ERX197246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.76 |
| Max. Negotiated Rate |
$165.61 |
| Rate for Payer: Blue Shield of California Commercial |
$138.72
|
| Rate for Payer: Blue Shield of California EPN |
$99.75
|
| Rate for Payer: Cash Price |
$87.67
|
| Rate for Payer: Cigna of CA HMO |
$136.38
|
| Rate for Payer: Cigna of CA PPO |
$136.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$77.93
|
| Rate for Payer: Galaxy Health WC |
$165.61
|
| Rate for Payer: Global Benefits Group Commercial |
$116.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$129.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$74.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.76
|
| Rate for Payer: Multiplan Commercial |
$155.86
|
| Rate for Payer: Networks By Design Commercial |
$126.64
|
| Rate for Payer: Prime Health Services Commercial |
$165.61
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
|
IP
|
$779.30
|
|
|
Service Code
|
NDC 0069-0193-01
|
| Hospital Charge Code |
ERX220449
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$187.03 |
| Max. Negotiated Rate |
$662.40 |
| Rate for Payer: Blue Shield of California Commercial |
$554.86
|
| Rate for Payer: Blue Shield of California EPN |
$399.00
|
| Rate for Payer: Cash Price |
$350.69
|
| Rate for Payer: Cigna of CA HMO |
$545.51
|
| Rate for Payer: Cigna of CA PPO |
$545.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$311.72
|
| Rate for Payer: Galaxy Health WC |
$662.40
|
| Rate for Payer: Global Benefits Group Commercial |
$467.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$519.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$296.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$187.03
|
| Rate for Payer: Multiplan Commercial |
$623.44
|
| Rate for Payer: Networks By Design Commercial |
$506.54
|
| Rate for Payer: Prime Health Services Commercial |
$662.40
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
|
OP
|
$779.30
|
|
|
Service Code
|
NDC 0069-0193-01
|
| Hospital Charge Code |
ERX220449
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$187.03 |
| Max. Negotiated Rate |
$662.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$511.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$662.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$428.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$428.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$464.31
|
| Rate for Payer: Blue Distinction Transplant |
$467.58
|
| Rate for Payer: Blue Shield of California Commercial |
$574.34
|
| Rate for Payer: Blue Shield of California EPN |
$455.11
|
| Rate for Payer: Cash Price |
$350.69
|
| Rate for Payer: Cigna of CA HMO |
$545.51
|
| Rate for Payer: Cigna of CA PPO |
$545.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$662.40
|
| Rate for Payer: Dignity Health Media |
$662.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$662.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$311.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$311.72
|
| Rate for Payer: Galaxy Health WC |
$662.40
|
| Rate for Payer: Global Benefits Group Commercial |
$467.58
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$584.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$519.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$296.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$187.03
|
| Rate for Payer: Multiplan Commercial |
$623.44
|
| Rate for Payer: Networks By Design Commercial |
$506.54
|
| Rate for Payer: Prime Health Services Commercial |
$662.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$467.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$467.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$389.65
|
| Rate for Payer: United Healthcare All Other HMO |
$389.65
|
| Rate for Payer: United Healthcare HMO Rider |
$389.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$389.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$662.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$662.40
|
| Rate for Payer: Vantage Medical Group Senior |
$662.40
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
|
IP
|
$779.30
|
|
|
Service Code
|
NDC 0069-0136-01
|
| Hospital Charge Code |
ERX197247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$187.03 |
| Max. Negotiated Rate |
$662.40 |
| Rate for Payer: Blue Shield of California Commercial |
$554.86
|
| Rate for Payer: Blue Shield of California EPN |
$399.00
|
| Rate for Payer: Cash Price |
$350.69
|
| Rate for Payer: Cigna of CA HMO |
$545.51
|
| Rate for Payer: Cigna of CA PPO |
$545.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$311.72
|
| Rate for Payer: Galaxy Health WC |
$662.40
|
| Rate for Payer: Global Benefits Group Commercial |
$467.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$519.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$296.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$187.03
|
| Rate for Payer: Multiplan Commercial |
$623.44
|
| Rate for Payer: Networks By Design Commercial |
$506.54
|
| Rate for Payer: Prime Health Services Commercial |
$662.40
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
|
OP
|
$779.30
|
|
|
Service Code
|
NDC 0069-0136-01
|
| Hospital Charge Code |
ERX197247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$187.03 |
| Max. Negotiated Rate |
$662.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$511.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$662.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$428.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$428.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$464.31
|
| Rate for Payer: Blue Distinction Transplant |
$467.58
|
| Rate for Payer: Blue Shield of California Commercial |
$574.34
|
| Rate for Payer: Blue Shield of California EPN |
$455.11
|
| Rate for Payer: Cash Price |
$350.69
|
| Rate for Payer: Cigna of CA HMO |
$545.51
|
| Rate for Payer: Cigna of CA PPO |
$545.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$662.40
|
| Rate for Payer: Dignity Health Media |
$662.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$662.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$311.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$311.72
|
| Rate for Payer: Galaxy Health WC |
$662.40
|
| Rate for Payer: Global Benefits Group Commercial |
$467.58
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$584.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$519.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$296.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$187.03
|
| Rate for Payer: Multiplan Commercial |
$623.44
|
| Rate for Payer: Networks By Design Commercial |
$506.54
|
| Rate for Payer: Prime Health Services Commercial |
$662.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$467.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$467.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$389.65
|
| Rate for Payer: United Healthcare All Other HMO |
$389.65
|
| Rate for Payer: United Healthcare HMO Rider |
$389.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$389.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$662.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$662.40
|
| Rate for Payer: Vantage Medical Group Senior |
$662.40
|
|
|
BOTULISM IMMUNE GLOBULIN, HUMAN 100 MG INTRAVENOUS SOLUTION [213747]
|
Facility
|
IP
|
$271,800.00
|
|
|
Service Code
|
NDC 68403-1100-6
|
| Hospital Charge Code |
NDG213747
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65,232.00 |
| Max. Negotiated Rate |
$231,030.00 |
| Rate for Payer: Blue Shield of California Commercial |
$193,521.60
|
| Rate for Payer: Blue Shield of California EPN |
$139,161.60
|
| Rate for Payer: Cash Price |
$122,310.00
|
| Rate for Payer: Cigna of CA HMO |
$190,260.00
|
| Rate for Payer: Cigna of CA PPO |
$190,260.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$108,720.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$108,720.00
|
| Rate for Payer: Galaxy Health WC |
$231,030.00
|
| Rate for Payer: Global Benefits Group Commercial |
$163,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$181,290.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$103,555.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65,232.00
|
| Rate for Payer: Multiplan Commercial |
$217,440.00
|
| Rate for Payer: Networks By Design Commercial |
$135,900.00
|
| Rate for Payer: Prime Health Services Commercial |
$231,030.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$102,631.68
|
| Rate for Payer: United Healthcare All Other HMO |
$100,239.84
|
| Rate for Payer: United Healthcare HMO Rider |
$98,065.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$89,694.00
|
|
|
BOTULISM IMMUNE GLOBULIN, HUMAN 100 MG INTRAVENOUS SOLUTION [213747]
|
Facility
|
OP
|
$271,800.00
|
|
|
Service Code
|
NDC 68403-1100-6
|
| Hospital Charge Code |
NDG213747
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65,232.00 |
| Max. Negotiated Rate |
$231,030.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$178,273.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$231,030.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$149,490.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$149,490.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$161,938.44
|
| Rate for Payer: Blue Distinction Transplant |
$163,080.00
|
| Rate for Payer: Blue Shield of California Commercial |
$200,316.60
|
| Rate for Payer: Blue Shield of California EPN |
$158,731.20
|
| Rate for Payer: Cash Price |
$122,310.00
|
| Rate for Payer: Cigna of CA HMO |
$190,260.00
|
| Rate for Payer: Cigna of CA PPO |
$190,260.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$231,030.00
|
| Rate for Payer: Dignity Health Media |
$231,030.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$231,030.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$108,720.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$108,720.00
|
| Rate for Payer: Galaxy Health WC |
$231,030.00
|
| Rate for Payer: Global Benefits Group Commercial |
$163,080.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$203,850.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$181,290.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$103,555.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65,232.00
|
| Rate for Payer: Multiplan Commercial |
$217,440.00
|
| Rate for Payer: Networks By Design Commercial |
$135,900.00
|
| Rate for Payer: Prime Health Services Commercial |
$231,030.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$163,080.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$163,080.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$135,900.00
|
| Rate for Payer: United Healthcare All Other HMO |
$135,900.00
|
| Rate for Payer: United Healthcare HMO Rider |
$135,900.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$135,900.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$231,030.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231,030.00
|
| Rate for Payer: Vantage Medical Group Senior |
$231,030.00
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$21,217.68
|
|
|
Service Code
|
APR-DRG 1324
|
| Min. Negotiated Rate |
$16,276.19 |
| Max. Negotiated Rate |
$21,217.68 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16,276.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21,217.68
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$13,318.68
|
|
|
Service Code
|
APR-DRG 1323
|
| Min. Negotiated Rate |
$10,216.83 |
| Max. Negotiated Rate |
$13,318.68 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,216.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,318.68
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$7,929.14
|
|
|
Service Code
|
APR-DRG 1322
|
| Min. Negotiated Rate |
$6,082.48 |
| Max. Negotiated Rate |
$7,929.14 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,082.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7,929.14
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$6,038.64
|
|
|
Service Code
|
APR-DRG 1321
|
| Min. Negotiated Rate |
$4,632.27 |
| Max. Negotiated Rate |
$6,038.64 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,632.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,038.64
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$18,373.04
|
|
|
Service Code
|
APR-DRG 0563
|
| Min. Negotiated Rate |
$14,094.05 |
| Max. Negotiated Rate |
$18,373.04 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14,094.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,373.04
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$13,343.51
|
|
|
Service Code
|
APR-DRG 0562
|
| Min. Negotiated Rate |
$10,235.88 |
| Max. Negotiated Rate |
$13,343.51 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,235.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,343.51
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$9,349.67
|
|
|
Service Code
|
APR-DRG 0561
|
| Min. Negotiated Rate |
$7,172.18 |
| Max. Negotiated Rate |
$9,349.67 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,172.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,349.67
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$29,427.03
|
|
|
Service Code
|
APR-DRG 0564
|
| Min. Negotiated Rate |
$22,573.63 |
| Max. Negotiated Rate |
$29,427.03 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22,573.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29,427.03
|
|
|
BREAST PROCEDURES EXCEPT MASTECTOMY
|
Facility
|
IP
|
$16,502.05
|
|
|
Service Code
|
APR-DRG 3631
|
| Min. Negotiated Rate |
$12,658.81 |
| Max. Negotiated Rate |
$16,502.05 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,658.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,502.05
|
|
