|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 60505-2502-1
|
| Hospital Charge Code |
1712456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Blue Shield of California Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.64
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 70710-1157-3
|
| Hospital Charge Code |
1712456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 60505-2502-1
|
| Hospital Charge Code |
1712456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.91
|
| Rate for Payer: Blue Distinction Transplant |
$1.92
|
| Rate for Payer: Blue Shield of California Commercial |
$2.36
|
| Rate for Payer: Blue Shield of California EPN |
$1.87
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Media |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.60
|
| Rate for Payer: United Healthcare All Other HMO |
$1.60
|
| Rate for Payer: United Healthcare HMO Rider |
$1.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 70710-1157-3
|
| Hospital Charge Code |
1712456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.78
|
| Rate for Payer: Blue Distinction Transplant |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Media |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare HMO Rider |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 62332-062-30
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.57
|
| Rate for Payer: Blue Distinction Transplant |
$3.60
|
| Rate for Payer: Blue Shield of California Commercial |
$4.42
|
| Rate for Payer: Blue Shield of California EPN |
$3.50
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Media |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.00
|
| Rate for Payer: United Healthcare All Other HMO |
$3.00
|
| Rate for Payer: United Healthcare HMO Rider |
$3.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$3.32
|
|
|
Service Code
|
NDC 60505-2503-1
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.98
|
| Rate for Payer: Blue Distinction Transplant |
$1.99
|
| Rate for Payer: Blue Shield of California Commercial |
$2.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.94
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.82
|
| Rate for Payer: Dignity Health Media |
$2.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.66
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.66
|
| Rate for Payer: United Healthcare All Other HMO |
$1.66
|
| Rate for Payer: United Healthcare HMO Rider |
$1.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Vantage Medical Group Senior |
$2.82
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 23155-044-03
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.52
|
| Rate for Payer: Blue Distinction Transplant |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.75
|
| Rate for Payer: Dignity Health Media |
$0.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.75
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 23155-044-03
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.75
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$3.32
|
|
|
Service Code
|
NDC 60505-2503-1
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Blue Shield of California Commercial |
$2.36
|
| Rate for Payer: Blue Shield of California EPN |
$1.70
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.66
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 62332-062-30
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Blue Shield of California Commercial |
$4.27
|
| Rate for Payer: Blue Shield of California EPN |
$3.07
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
IP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-01
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.13 |
| Max. Negotiated Rate |
$14.64 |
| Rate for Payer: Blue Shield of California Commercial |
$12.26
|
| Rate for Payer: Blue Shield of California EPN |
$8.82
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.89
|
| Rate for Payer: Galaxy Health WC |
$14.64
|
| Rate for Payer: Global Benefits Group Commercial |
$10.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.13
|
| Rate for Payer: Multiplan Commercial |
$13.78
|
| Rate for Payer: Networks By Design Commercial |
$11.19
|
| Rate for Payer: Prime Health Services Commercial |
$14.64
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
OP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-02
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.13 |
| Max. Negotiated Rate |
$14.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.26
|
| Rate for Payer: Blue Distinction Transplant |
$10.33
|
| Rate for Payer: Blue Shield of California Commercial |
$12.69
|
| Rate for Payer: Blue Shield of California EPN |
$10.06
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: Cigna of CA HMO |
$11.02
|
| Rate for Payer: Cigna of CA PPO |
$12.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.64
|
| Rate for Payer: Dignity Health Media |
$14.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.89
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.89
|
| Rate for Payer: Galaxy Health WC |
$14.64
|
| Rate for Payer: Global Benefits Group Commercial |
$10.33
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$12.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.13
|
| Rate for Payer: Multiplan Commercial |
$13.78
|
| Rate for Payer: Networks By Design Commercial |
$11.19
|
| Rate for Payer: Prime Health Services Commercial |
$14.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.61
|
| Rate for Payer: United Healthcare All Other HMO |
$8.61
|
| Rate for Payer: United Healthcare HMO Rider |
$8.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.64
|
| Rate for Payer: Vantage Medical Group Senior |
$14.64
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
IP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-02
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.13 |
| Max. Negotiated Rate |
$14.64 |
| Rate for Payer: Blue Shield of California Commercial |
$12.26
|
| Rate for Payer: Blue Shield of California EPN |
$8.82
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.89
|
| Rate for Payer: Galaxy Health WC |
$14.64
|
| Rate for Payer: Global Benefits Group Commercial |
$10.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.13
|
| Rate for Payer: Multiplan Commercial |
$13.78
|
| Rate for Payer: Networks By Design Commercial |
$11.19
|
| Rate for Payer: Prime Health Services Commercial |
$14.64
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
OP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-01
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.13 |
| Max. Negotiated Rate |
$14.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.26
|
| Rate for Payer: Blue Distinction Transplant |
$10.33
|
| Rate for Payer: Blue Shield of California Commercial |
$12.69
|
| Rate for Payer: Blue Shield of California EPN |
$10.06
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: Cigna of CA HMO |
$11.02
|
| Rate for Payer: Cigna of CA PPO |
$12.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.64
|
| Rate for Payer: Dignity Health Media |
$14.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.89
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.89
|
| Rate for Payer: Galaxy Health WC |
$14.64
|
| Rate for Payer: Global Benefits Group Commercial |
$10.33
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$12.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.13
|
| Rate for Payer: Multiplan Commercial |
$13.78
|
| Rate for Payer: Networks By Design Commercial |
$11.19
|
| Rate for Payer: Prime Health Services Commercial |
$14.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.61
|
| Rate for Payer: United Healthcare All Other HMO |
$8.61
|
| Rate for Payer: United Healthcare HMO Rider |
$8.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.64
|
| Rate for Payer: Vantage Medical Group Senior |
$14.64
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 16729-034-10
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 16729-034-10
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Blue Distinction Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Media |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-11
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-15
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-15
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: Blue Distinction Transplant |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Media |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-11
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: Blue Distinction Transplant |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Media |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
LEUCINE 0.1 GRAM-15 KCAL/4 GRAM ORAL POWDER PACKET [78240]
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
NDC 5060054920
|
| Hospital Charge Code |
ERX78240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Blue Shield of California Commercial |
$3.42
|
| Rate for Payer: Blue Shield of California EPN |
$2.46
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna of CA HMO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$3.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Galaxy Health WC |
$4.08
|
| Rate for Payer: Global Benefits Group Commercial |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: Networks By Design Commercial |
$3.12
|
| Rate for Payer: Prime Health Services Commercial |
$4.08
|
|
|
LEUCINE 0.1 GRAM-15 KCAL/4 GRAM ORAL POWDER PACKET [78240]
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
NDC 5060054920
|
| Hospital Charge Code |
ERX78240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.86
|
| Rate for Payer: Blue Distinction Transplant |
$2.88
|
| Rate for Payer: Blue Shield of California Commercial |
$3.54
|
| Rate for Payer: Blue Shield of California EPN |
$2.80
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna of CA HMO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$3.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Media |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.92
|
| Rate for Payer: Galaxy Health WC |
$4.08
|
| Rate for Payer: Global Benefits Group Commercial |
$2.88
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: Networks By Design Commercial |
$3.12
|
| Rate for Payer: Prime Health Services Commercial |
$4.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.40
|
| Rate for Payer: United Healthcare All Other HMO |
$2.40
|
| Rate for Payer: United Healthcare HMO Rider |
$2.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]
|
Facility
|
IP
|
$19.20
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.61 |
| Max. Negotiated Rate |
$16.32 |
| Rate for Payer: Blue Shield of California Commercial |
$13.67
|
| Rate for Payer: Blue Shield of California Commercial |
$17.09
|
| Rate for Payer: Blue Shield of California EPN |
$9.83
|
| Rate for Payer: Blue Shield of California EPN |
$12.29
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna of CA HMO |
$13.44
|
| Rate for Payer: Cigna of CA HMO |
$16.80
|
| Rate for Payer: Cigna of CA PPO |
$16.80
|
| Rate for Payer: Cigna of CA PPO |
$13.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.60
|
| Rate for Payer: Galaxy Health WC |
$16.32
|
| Rate for Payer: Galaxy Health WC |
$20.40
|
| Rate for Payer: Global Benefits Group Commercial |
$14.40
|
| Rate for Payer: Global Benefits Group Commercial |
$11.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.76
|
| Rate for Payer: Multiplan Commercial |
$15.36
|
| Rate for Payer: Multiplan Commercial |
$19.20
|
| Rate for Payer: Networks By Design Commercial |
$9.60
|
| Rate for Payer: Networks By Design Commercial |
$12.00
|
| Rate for Payer: Prime Health Services Commercial |
$16.32
|
| Rate for Payer: Prime Health Services Commercial |
$20.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.06
|
| Rate for Payer: United Healthcare All Other HMO |
$7.08
|
| Rate for Payer: United Healthcare All Other HMO |
$8.85
|
| Rate for Payer: United Healthcare HMO Rider |
$6.93
|
| Rate for Payer: United Healthcare HMO Rider |
$8.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.92
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]
|
Facility
|
OP
|
$19.20
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.61 |
| Max. Negotiated Rate |
$42.83 |
| Rate for Payer: Aetna of CA HMO/PPO |
$28.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$28.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.83
|
| Rate for Payer: Blue Distinction Transplant |
$11.52
|
| Rate for Payer: Blue Distinction Transplant |
$14.40
|
| Rate for Payer: Blue Shield of California Commercial |
$14.15
|
| Rate for Payer: Blue Shield of California Commercial |
$17.69
|
| Rate for Payer: Blue Shield of California EPN |
$9.74
|
| Rate for Payer: Blue Shield of California EPN |
$9.74
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cigna of CA HMO |
$13.44
|
| Rate for Payer: Cigna of CA HMO |
$16.80
|
| Rate for Payer: Cigna of CA PPO |
$13.44
|
| Rate for Payer: Cigna of CA PPO |
$16.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.32
|
| Rate for Payer: Dignity Health Media |
$20.40
|
| Rate for Payer: Dignity Health Media |
$16.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.60
|
| Rate for Payer: Galaxy Health WC |
$16.32
|
| Rate for Payer: Galaxy Health WC |
$20.40
|
| Rate for Payer: Global Benefits Group Commercial |
$14.40
|
| Rate for Payer: Global Benefits Group Commercial |
$11.52
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$18.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$14.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.61
|
| Rate for Payer: Multiplan Commercial |
$19.20
|
| Rate for Payer: Multiplan Commercial |
$15.36
|
| Rate for Payer: Networks By Design Commercial |
$9.60
|
| Rate for Payer: Networks By Design Commercial |
$12.00
|
| Rate for Payer: Prime Health Services Commercial |
$20.40
|
| Rate for Payer: Prime Health Services Commercial |
$16.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$14.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$12.00
|
| Rate for Payer: United Healthcare All Other HMO |
$12.00
|
| Rate for Payer: United Healthcare All Other HMO |
$9.60
|
| Rate for Payer: United Healthcare HMO Rider |
$12.00
|
| Rate for Payer: United Healthcare HMO Rider |
$9.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$16.32
|
|
|
LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [15370]
|
Facility
|
IP
|
$2.84
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
NDG15370A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Blue Shield of California Commercial |
$2.02
|
| Rate for Payer: Blue Shield of California EPN |
$1.45
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cigna of CA HMO |
$1.99
|
| Rate for Payer: Cigna of CA PPO |
$1.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.14
|
| Rate for Payer: Galaxy Health WC |
$2.41
|
| Rate for Payer: Global Benefits Group Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.27
|
| Rate for Payer: Networks By Design Commercial |
$1.42
|
| Rate for Payer: Prime Health Services Commercial |
$2.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.07
|
| Rate for Payer: United Healthcare All Other HMO |
$1.05
|
| Rate for Payer: United Healthcare HMO Rider |
$1.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.94
|
|
