|
LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [15370]
|
Facility
|
OP
|
$2.84
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
NDG15370A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$42.83 |
| Rate for Payer: Aetna of CA HMO/PPO |
$28.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.83
|
| Rate for Payer: Blue Distinction Transplant |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2.09
|
| Rate for Payer: Blue Shield of California EPN |
$9.74
|
| Rate for Payer: Cash Price |
$1.28
|
| 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: Dignity Health Commercial/Exchange |
$2.41
|
| Rate for Payer: Dignity Health Media |
$2.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.41
|
| 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: Health Plan of Nevada (Sierra) Other |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.97
|
| 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: Temecula Valley Physicians Medical Group Commercial |
$1.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.42
|
| Rate for Payer: United Healthcare All Other HMO |
$1.42
|
| Rate for Payer: United Healthcare HMO Rider |
$1.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.41
|
| Rate for Payer: Vantage Medical Group Senior |
$2.41
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$6.65
|
|
|
Service Code
|
NDC 0054-4497-10
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$5.65 |
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California EPN |
$3.40
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cigna of CA HMO |
$4.66
|
| Rate for Payer: Cigna of CA PPO |
$4.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.66
|
| Rate for Payer: Galaxy Health WC |
$5.65
|
| Rate for Payer: Global Benefits Group Commercial |
$3.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: Multiplan Commercial |
$5.32
|
| Rate for Payer: Networks By Design Commercial |
$4.32
|
| Rate for Payer: Prime Health Services Commercial |
$5.65
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$6.65
|
|
|
Service Code
|
NDC 0054-4497-10
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$5.65 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.96
|
| Rate for Payer: Blue Distinction Transplant |
$3.99
|
| Rate for Payer: Blue Shield of California Commercial |
$4.90
|
| Rate for Payer: Blue Shield of California EPN |
$3.88
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cigna of CA HMO |
$4.66
|
| Rate for Payer: Cigna of CA PPO |
$4.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.65
|
| Rate for Payer: Dignity Health Media |
$5.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.66
|
| Rate for Payer: Galaxy Health WC |
$5.65
|
| Rate for Payer: Global Benefits Group Commercial |
$3.99
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: Multiplan Commercial |
$5.32
|
| Rate for Payer: Networks By Design Commercial |
$4.32
|
| Rate for Payer: Prime Health Services Commercial |
$5.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.32
|
| Rate for Payer: United Healthcare All Other HMO |
$3.32
|
| Rate for Payer: United Healthcare HMO Rider |
$3.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.65
|
| Rate for Payer: Vantage Medical Group Senior |
$5.65
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$6.65
|
|
|
Service Code
|
NDC 69315-185-24
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$5.65 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.96
|
| Rate for Payer: Blue Distinction Transplant |
$3.99
|
| Rate for Payer: Blue Shield of California Commercial |
$4.90
|
| Rate for Payer: Blue Shield of California EPN |
$3.88
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cigna of CA HMO |
$4.66
|
| Rate for Payer: Cigna of CA PPO |
$4.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.65
|
| Rate for Payer: Dignity Health Media |
$5.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.66
|
| Rate for Payer: Galaxy Health WC |
$5.65
|
| Rate for Payer: Global Benefits Group Commercial |
$3.99
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: Multiplan Commercial |
$5.32
|
| Rate for Payer: Networks By Design Commercial |
$4.32
|
| Rate for Payer: Prime Health Services Commercial |
$5.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.32
|
| Rate for Payer: United Healthcare All Other HMO |
$3.32
|
| Rate for Payer: United Healthcare HMO Rider |
$3.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.65
|
| Rate for Payer: Vantage Medical Group Senior |
$5.65
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$7.48
|
|
|
Service Code
|
NDC 69315-185-12
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$6.36 |
| Rate for Payer: Blue Shield of California Commercial |
$5.33
|
| Rate for Payer: Blue Shield of California EPN |
$3.83
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cigna of CA HMO |
$5.24
|
| Rate for Payer: Cigna of CA PPO |
$5.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.99
|
| Rate for Payer: Galaxy Health WC |
$6.36
|
| Rate for Payer: Global Benefits Group Commercial |
$4.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$5.98
|
| Rate for Payer: Networks By Design Commercial |
$4.86
|
| Rate for Payer: Prime Health Services Commercial |
$6.36
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$7.48
|
|
|
Service Code
|
NDC 0054-4497-05
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$6.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.46
|
| Rate for Payer: Blue Distinction Transplant |
$4.49
|
| Rate for Payer: Blue Shield of California Commercial |
$5.51
|
| Rate for Payer: Blue Shield of California EPN |
$4.37
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cigna of CA HMO |
$5.24
|
| Rate for Payer: Cigna of CA PPO |
$5.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.36
|
| Rate for Payer: Dignity Health Media |
$6.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.99
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.99
|
| Rate for Payer: Galaxy Health WC |
$6.36
|
| Rate for Payer: Global Benefits Group Commercial |
$4.49
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$5.98
|
| Rate for Payer: Networks By Design Commercial |
$4.86
|
| Rate for Payer: Prime Health Services Commercial |
$6.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.74
|
| Rate for Payer: United Healthcare All Other HMO |
$3.74
|
| Rate for Payer: United Healthcare HMO Rider |
$3.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: Vantage Medical Group Senior |
$6.36
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$7.48
|
|
|
Service Code
|
NDC 69315-185-12
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$6.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.46
|
| Rate for Payer: Blue Distinction Transplant |
$4.49
|
| Rate for Payer: Blue Shield of California Commercial |
$5.51
|
| Rate for Payer: Blue Shield of California EPN |
$4.37
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cigna of CA HMO |
$5.24
|
| Rate for Payer: Cigna of CA PPO |
$5.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.36
|
| Rate for Payer: Dignity Health Media |
$6.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.99
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.99
|
| Rate for Payer: Galaxy Health WC |
$6.36
|
| Rate for Payer: Global Benefits Group Commercial |
$4.49
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$5.98
|
| Rate for Payer: Networks By Design Commercial |
$4.86
|
| Rate for Payer: Prime Health Services Commercial |
$6.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.74
|
| Rate for Payer: United Healthcare All Other HMO |
$3.74
|
| Rate for Payer: United Healthcare HMO Rider |
$3.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: Vantage Medical Group Senior |
$6.36
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$6.65
|
|
|
Service Code
|
NDC 69315-185-24
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$5.65 |
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California EPN |
$3.40
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cigna of CA HMO |
$4.66
|
| Rate for Payer: Cigna of CA PPO |
$4.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.66
|
| Rate for Payer: Galaxy Health WC |
$5.65
|
| Rate for Payer: Global Benefits Group Commercial |
$3.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: Multiplan Commercial |
$5.32
|
| Rate for Payer: Networks By Design Commercial |
$4.32
|
| Rate for Payer: Prime Health Services Commercial |
$5.65
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$7.48
|
|
|
Service Code
|
NDC 0054-4497-05
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$6.36 |
| Rate for Payer: Blue Shield of California Commercial |
$5.33
|
| Rate for Payer: Blue Shield of California EPN |
$3.83
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cigna of CA HMO |
$5.24
|
| Rate for Payer: Cigna of CA PPO |
$5.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.99
|
| Rate for Payer: Galaxy Health WC |
$6.36
|
| Rate for Payer: Global Benefits Group Commercial |
$4.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$5.98
|
| Rate for Payer: Networks By Design Commercial |
$4.86
|
| Rate for Payer: Prime Health Services Commercial |
$6.36
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]
|
Facility
|
OP
|
$27.67
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
ERX15426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.64 |
| 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: Aetna of CA HMO/PPO |
$28.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.22
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$42.83
|
| Rate for Payer: Blue Distinction Transplant |
$28.80
|
| Rate for Payer: Blue Distinction Transplant |
$17.28
|
| Rate for Payer: Blue Distinction Transplant |
$16.60
|
| Rate for Payer: Blue Shield of California Commercial |
$21.23
|
| Rate for Payer: Blue Shield of California Commercial |
$20.39
|
| Rate for Payer: Blue Shield of California Commercial |
$35.38
|
| Rate for Payer: Blue Shield of California EPN |
$9.74
|
| 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 |
$21.60
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cigna of CA HMO |
$33.60
|
| Rate for Payer: Cigna of CA HMO |
$19.37
|
| Rate for Payer: Cigna of CA HMO |
$20.16
|
| Rate for Payer: Cigna of CA PPO |
$33.60
|
| Rate for Payer: Cigna of CA PPO |
$19.37
|
| Rate for Payer: Cigna of CA PPO |
$20.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Media |
$24.48
|
| Rate for Payer: Dignity Health Media |
$23.52
|
| Rate for Payer: Dignity Health Media |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.52
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Galaxy Health WC |
$23.52
|
| Rate for Payer: Galaxy Health WC |
$24.48
|
| Rate for Payer: Global Benefits Group Commercial |
$17.28
|
| Rate for Payer: Global Benefits Group Commercial |
$16.60
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$20.75
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$21.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$36.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.46
|
| 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: Kaiser Permanente of CA Medi-Cal |
$16.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.91
|
| Rate for Payer: Multiplan Commercial |
$23.04
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: Multiplan Commercial |
$22.14
|
| Rate for Payer: Networks By Design Commercial |
$14.40
|
| Rate for Payer: Networks By Design Commercial |
$24.00
|
| Rate for Payer: Networks By Design Commercial |
$13.84
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
| Rate for Payer: Prime Health Services Commercial |
$23.52
|
| Rate for Payer: Prime Health Services Commercial |
$24.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Other HMO |
$24.00
|
| Rate for Payer: United Healthcare All Other HMO |
$13.84
|
| Rate for Payer: United Healthcare All Other HMO |
$14.40
|
| Rate for Payer: United Healthcare HMO Rider |
$13.84
|
| Rate for Payer: United Healthcare HMO Rider |
$14.40
|
| Rate for Payer: United Healthcare HMO Rider |
$24.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$24.48
|
| Rate for Payer: Vantage Medical Group Senior |
$23.52
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]
|
Facility
|
IP
|
$27.67
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
ERX15426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.64 |
| Max. Negotiated Rate |
$23.52 |
| Rate for Payer: Blue Shield of California Commercial |
$19.70
|
| Rate for Payer: Blue Shield of California Commercial |
$20.51
|
| Rate for Payer: Blue Shield of California Commercial |
$34.18
|
| Rate for Payer: Blue Shield of California EPN |
$14.75
|
| Rate for Payer: Blue Shield of California EPN |
$24.58
|
| Rate for Payer: Blue Shield of California EPN |
$14.17
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna of CA HMO |
$33.60
|
| Rate for Payer: Cigna of CA HMO |
$20.16
|
| Rate for Payer: Cigna of CA HMO |
$19.37
|
| Rate for Payer: Cigna of CA PPO |
$19.37
|
| Rate for Payer: Cigna of CA PPO |
$20.16
|
| Rate for Payer: Cigna of CA PPO |
$33.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.52
|
| Rate for Payer: Galaxy Health WC |
$24.48
|
| Rate for Payer: Galaxy Health WC |
$23.52
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Global Benefits Group Commercial |
$16.60
|
| Rate for Payer: Global Benefits Group Commercial |
$17.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Multiplan Commercial |
$22.14
|
| Rate for Payer: Multiplan Commercial |
$23.04
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: Networks By Design Commercial |
$14.40
|
| Rate for Payer: Networks By Design Commercial |
$13.84
|
| Rate for Payer: Networks By Design Commercial |
$24.00
|
| Rate for Payer: Prime Health Services Commercial |
$23.52
|
| Rate for Payer: Prime Health Services Commercial |
$24.48
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.45
|
| Rate for Payer: United Healthcare All Other HMO |
$10.62
|
| Rate for Payer: United Healthcare All Other HMO |
$10.20
|
| Rate for Payer: United Healthcare All Other HMO |
$17.70
|
| Rate for Payer: United Healthcare HMO Rider |
$17.32
|
| Rate for Payer: United Healthcare HMO Rider |
$9.98
|
| Rate for Payer: United Healthcare HMO Rider |
$10.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.84
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]
|
Facility
|
IP
|
$22.74
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$19.33 |
| Rate for Payer: Blue Shield of California Commercial |
$16.19
|
| Rate for Payer: Blue Shield of California Commercial |
$59.81
|
| Rate for Payer: Blue Shield of California Commercial |
$15.04
|
| Rate for Payer: Blue Shield of California Commercial |
$22.21
|
| Rate for Payer: Blue Shield of California EPN |
$43.01
|
| Rate for Payer: Blue Shield of California EPN |
$11.64
|
| Rate for Payer: Blue Shield of California EPN |
$15.97
|
| Rate for Payer: Blue Shield of California EPN |
$10.81
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cigna of CA HMO |
$15.92
|
| Rate for Payer: Cigna of CA HMO |
$21.84
|
| Rate for Payer: Cigna of CA HMO |
$58.80
|
| Rate for Payer: Cigna of CA HMO |
$14.78
|
| Rate for Payer: Cigna of CA PPO |
$14.78
|
| Rate for Payer: Cigna of CA PPO |
$58.80
|
| Rate for Payer: Cigna of CA PPO |
$21.84
|
| Rate for Payer: Cigna of CA PPO |
$15.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$33.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.45
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.48
|
| Rate for Payer: Galaxy Health WC |
$19.33
|
| Rate for Payer: Galaxy Health WC |
$17.95
|
| Rate for Payer: Galaxy Health WC |
$26.52
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Global Benefits Group Commercial |
$12.67
|
| Rate for Payer: Global Benefits Group Commercial |
$13.64
|
| Rate for Payer: Global Benefits Group Commercial |
$18.72
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.07
|
| Rate for Payer: Multiplan Commercial |
$16.90
|
| Rate for Payer: Multiplan Commercial |
$18.19
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: Networks By Design Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$42.00
|
| Rate for Payer: Networks By Design Commercial |
$11.37
|
| Rate for Payer: Networks By Design Commercial |
$15.60
|
| Rate for Payer: Prime Health Services Commercial |
$26.52
|
| Rate for Payer: Prime Health Services Commercial |
$19.33
|
| Rate for Payer: Prime Health Services Commercial |
$71.40
|
| Rate for Payer: Prime Health Services Commercial |
$17.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$31.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.97
|
| Rate for Payer: United Healthcare All Other HMO |
$11.51
|
| Rate for Payer: United Healthcare All Other HMO |
$30.98
|
| Rate for Payer: United Healthcare All Other HMO |
$8.39
|
| Rate for Payer: United Healthcare All Other HMO |
$7.79
|
| Rate for Payer: United Healthcare HMO Rider |
$11.26
|
| Rate for Payer: United Healthcare HMO Rider |
$8.20
|
| Rate for Payer: United Healthcare HMO Rider |
$30.31
|
| Rate for Payer: United Healthcare HMO Rider |
$7.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$27.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.50
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.74 |
| Max. Negotiated Rate |
$71.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$28.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$28.08
|
| 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 |
$26.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$46.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.16
|
| 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: 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 |
$13.64
|
| Rate for Payer: Blue Distinction Transplant |
$12.67
|
| Rate for Payer: Blue Distinction Transplant |
$50.40
|
| Rate for Payer: Blue Distinction Transplant |
$18.72
|
| Rate for Payer: Blue Shield of California Commercial |
$22.99
|
| Rate for Payer: Blue Shield of California Commercial |
$16.76
|
| Rate for Payer: Blue Shield of California Commercial |
$15.57
|
| Rate for Payer: Blue Shield of California Commercial |
$61.91
|
| Rate for Payer: Blue Shield of California EPN |
$9.74
|
| Rate for Payer: Blue Shield of California EPN |
$9.74
|
| 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 |
$37.80
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cigna of CA HMO |
$21.84
|
| Rate for Payer: Cigna of CA HMO |
$15.92
|
| Rate for Payer: Cigna of CA HMO |
$58.80
|
| Rate for Payer: Cigna of CA HMO |
$14.78
|
| Rate for Payer: Cigna of CA PPO |
$58.80
|
| Rate for Payer: Cigna of CA PPO |
$21.84
|
| Rate for Payer: Cigna of CA PPO |
$15.92
|
| Rate for Payer: Cigna of CA PPO |
$14.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.40
|
| Rate for Payer: Dignity Health Media |
$71.40
|
| Rate for Payer: Dignity Health Media |
$17.95
|
| Rate for Payer: Dignity Health Media |
$19.33
|
| Rate for Payer: Dignity Health Media |
$26.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: EPIC Health Plan Transplant |
$33.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.45
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.48
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Galaxy Health WC |
$26.52
|
| Rate for Payer: Galaxy Health WC |
$19.33
|
| Rate for Payer: Galaxy Health WC |
$17.95
|
| Rate for Payer: Global Benefits Group Commercial |
$12.67
|
| Rate for Payer: Global Benefits Group Commercial |
$18.72
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Global Benefits Group Commercial |
$13.64
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$23.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$15.84
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$63.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$17.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.09
|
| 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: 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 |
$5.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.16
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: Multiplan Commercial |
$18.19
|
| Rate for Payer: Multiplan Commercial |
$16.90
|
| Rate for Payer: Networks By Design Commercial |
$15.60
|
| Rate for Payer: Networks By Design Commercial |
$11.37
|
| Rate for Payer: Networks By Design Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$42.00
|
| Rate for Payer: Prime Health Services Commercial |
$71.40
|
| Rate for Payer: Prime Health Services Commercial |
$17.95
|
| Rate for Payer: Prime Health Services Commercial |
$26.52
|
| Rate for Payer: Prime Health Services Commercial |
$19.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$50.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.67
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$50.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.67
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.37
|
| Rate for Payer: United Healthcare All Other HMO |
$10.56
|
| Rate for Payer: United Healthcare All Other HMO |
$15.60
|
| Rate for Payer: United Healthcare All Other HMO |
$42.00
|
| Rate for Payer: United Healthcare All Other HMO |
$11.37
|
| Rate for Payer: United Healthcare HMO Rider |
$42.00
|
| Rate for Payer: United Healthcare HMO Rider |
$10.56
|
| Rate for Payer: United Healthcare HMO Rider |
$11.37
|
| Rate for Payer: United Healthcare HMO Rider |
$15.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$42.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$17.95
|
| Rate for Payer: Vantage Medical Group Senior |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$26.52
|
| Rate for Payer: Vantage Medical Group Senior |
$19.33
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]
|
Facility
|
IP
|
$103.43
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
ERX23617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.82 |
| Max. Negotiated Rate |
$87.92 |
| Rate for Payer: Blue Shield of California Commercial |
$73.64
|
| Rate for Payer: Blue Shield of California Commercial |
$85.44
|
| Rate for Payer: Blue Shield of California EPN |
$52.96
|
| Rate for Payer: Blue Shield of California EPN |
$61.44
|
| Rate for Payer: Cash Price |
$46.54
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna of CA HMO |
$72.40
|
| Rate for Payer: Cigna of CA HMO |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$72.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.00
|
| Rate for Payer: Galaxy Health WC |
$87.92
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Global Benefits Group Commercial |
$62.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.80
|
| Rate for Payer: Multiplan Commercial |
$82.74
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Networks By Design Commercial |
$51.72
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Prime Health Services Commercial |
$87.92
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$39.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$45.31
|
| Rate for Payer: United Healthcare All Other HMO |
$38.14
|
| Rate for Payer: United Healthcare All Other HMO |
$44.26
|
| Rate for Payer: United Healthcare HMO Rider |
$37.32
|
| Rate for Payer: United Healthcare HMO Rider |
$43.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$39.60
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]
|
Facility
|
OP
|
$103.43
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
ERX23617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.74 |
| Max. Negotiated Rate |
$87.92 |
| 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 |
$102.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$87.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$56.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$66.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$56.89
|
| 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 |
$62.06
|
| Rate for Payer: Blue Distinction Transplant |
$72.00
|
| Rate for Payer: Blue Shield of California Commercial |
$76.23
|
| Rate for Payer: Blue Shield of California Commercial |
$88.44
|
| 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 |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$46.54
|
| Rate for Payer: Cash Price |
$46.54
|
| Rate for Payer: Cigna of CA HMO |
$72.40
|
| Rate for Payer: Cigna of CA HMO |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$72.40
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.92
|
| Rate for Payer: Dignity Health Media |
$102.00
|
| Rate for Payer: Dignity Health Media |
$87.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$87.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.00
|
| Rate for Payer: Galaxy Health WC |
$87.92
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Global Benefits Group Commercial |
$62.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$90.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$77.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.99
|
| 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 |
$28.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.82
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Multiplan Commercial |
$82.74
|
| Rate for Payer: Networks By Design Commercial |
$51.72
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
| Rate for Payer: Prime Health Services Commercial |
$87.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$72.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$62.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$72.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$62.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$51.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.00
|
| Rate for Payer: United Healthcare All Other HMO |
$60.00
|
| Rate for Payer: United Healthcare All Other HMO |
$51.72
|
| Rate for Payer: United Healthcare HMO Rider |
$60.00
|
| Rate for Payer: United Healthcare HMO Rider |
$51.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$51.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$87.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$87.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.00
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
| Rate for Payer: Vantage Medical Group Senior |
$87.92
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| 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 |
$5.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.60
|
| 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 |
$7.20
|
| Rate for Payer: Blue Distinction Transplant |
$3.80
|
| Rate for Payer: Blue Shield of California Commercial |
$8.84
|
| Rate for Payer: Blue Shield of California Commercial |
$4.67
|
| 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 |
$2.85
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna of CA HMO |
$8.40
|
| Rate for Payer: Cigna of CA HMO |
$4.44
|
| Rate for Payer: Cigna of CA PPO |
$8.40
|
| Rate for Payer: Cigna of CA PPO |
$4.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.20
|
| Rate for Payer: Dignity Health Media |
$5.39
|
| Rate for Payer: Dignity Health Media |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.54
|
| Rate for Payer: Galaxy Health WC |
$10.20
|
| Rate for Payer: Galaxy Health WC |
$5.39
|
| Rate for Payer: Global Benefits Group Commercial |
$3.80
|
| Rate for Payer: Global Benefits Group Commercial |
$7.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.76
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$9.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.00
|
| 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 |
$1.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
| Rate for Payer: Multiplan Commercial |
$9.60
|
| Rate for Payer: Networks By Design Commercial |
$6.00
|
| Rate for Payer: Networks By Design Commercial |
$3.17
|
| Rate for Payer: Prime Health Services Commercial |
$5.39
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.17
|
| Rate for Payer: United Healthcare All Other HMO |
$3.17
|
| Rate for Payer: United Healthcare All Other HMO |
$6.00
|
| Rate for Payer: United Healthcare HMO Rider |
$3.17
|
| Rate for Payer: United Healthcare HMO Rider |
$6.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.39
|
| Rate for Payer: Vantage Medical Group Senior |
$5.39
|
| Rate for Payer: Vantage Medical Group Senior |
$10.20
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$10.20 |
| Rate for Payer: Blue Shield of California Commercial |
$8.54
|
| Rate for Payer: Blue Shield of California Commercial |
$4.51
|
| Rate for Payer: Blue Shield of California EPN |
$6.14
|
| Rate for Payer: Blue Shield of California EPN |
$3.25
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cigna of CA HMO |
$8.40
|
| Rate for Payer: Cigna of CA HMO |
$4.44
|
| Rate for Payer: Cigna of CA PPO |
$4.44
|
| Rate for Payer: Cigna of CA PPO |
$8.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.54
|
| Rate for Payer: Galaxy Health WC |
$10.20
|
| Rate for Payer: Galaxy Health WC |
$5.39
|
| Rate for Payer: Global Benefits Group Commercial |
$3.80
|
| Rate for Payer: Global Benefits Group Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$9.60
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
| Rate for Payer: Networks By Design Commercial |
$6.00
|
| Rate for Payer: Networks By Design Commercial |
$3.17
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
| Rate for Payer: Prime Health Services Commercial |
$5.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.39
|
| Rate for Payer: United Healthcare All Other HMO |
$4.43
|
| Rate for Payer: United Healthcare All Other HMO |
$2.34
|
| Rate for Payer: United Healthcare HMO Rider |
$4.33
|
| Rate for Payer: United Healthcare HMO Rider |
$2.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.09
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 69315-184-03
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: Blue Distinction Transplant |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO |
$0.94
|
| Rate for Payer: Cigna of CA PPO |
$0.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Media |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Networks By Design Commercial |
$0.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.67
|
| Rate for Payer: United Healthcare All Other HMO |
$0.67
|
| Rate for Payer: United Healthcare HMO Rider |
$0.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.89
|
|
|
Service Code
|
NDC 0054-8496-19
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$1.32
|
| Rate for Payer: Cigna of CA PPO |
$1.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Galaxy Health WC |
$1.61
|
| Rate for Payer: Global Benefits Group Commercial |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Networks By Design Commercial |
$1.23
|
| Rate for Payer: Prime Health Services Commercial |
$1.61
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 69315-184-03
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.69
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO |
$0.94
|
| Rate for Payer: Cigna of CA PPO |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Networks By Design Commercial |
$0.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.14
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 0054-4496-13
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.69
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO |
$0.94
|
| Rate for Payer: Cigna of CA PPO |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Networks By Design Commercial |
$0.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.14
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 0054-8496-19
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.13
|
| Rate for Payer: Blue Distinction Transplant |
$1.13
|
| Rate for Payer: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California EPN |
$1.10
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$1.32
|
| Rate for Payer: Cigna of CA PPO |
$1.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.61
|
| Rate for Payer: Dignity Health Media |
$1.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.76
|
| Rate for Payer: Galaxy Health WC |
$1.61
|
| Rate for Payer: Global Benefits Group Commercial |
$1.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Networks By Design Commercial |
$1.23
|
| Rate for Payer: Prime Health Services Commercial |
$1.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.95
|
| Rate for Payer: United Healthcare All Other HMO |
$0.95
|
| Rate for Payer: United Healthcare HMO Rider |
$0.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.61
|
| Rate for Payer: Vantage Medical Group Senior |
$1.61
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 0054-4496-13
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: Blue Distinction Transplant |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO |
$0.94
|
| Rate for Payer: Cigna of CA PPO |
$0.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Media |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Networks By Design Commercial |
$0.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.67
|
| Rate for Payer: United Healthcare All Other HMO |
$0.67
|
| Rate for Payer: United Healthcare HMO Rider |
$0.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]
|
Facility
|
OP
|
$5,881.22
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
ERX21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$957.53 |
| Max. Negotiated Rate |
$9,840.53 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9,840.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,955.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,721.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,721.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$957.53
|
| Rate for Payer: Blue Distinction Transplant |
$3,528.73
|
| Rate for Payer: Blue Shield of California Commercial |
$4,334.46
|
| Rate for Payer: Blue Shield of California EPN |
$1,675.92
|
| Rate for Payer: Cash Price |
$2,646.55
|
| Rate for Payer: Cash Price |
$2,646.55
|
| Rate for Payer: Cigna of CA HMO |
$4,116.85
|
| Rate for Payer: Cigna of CA PPO |
$4,116.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,346.91
|
| Rate for Payer: Dignity Health Media |
$1,564.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,721.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,112.22
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1,564.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,564.60
|
| Rate for Payer: Galaxy Health WC |
$4,999.04
|
| Rate for Payer: Global Benefits Group Commercial |
$3,528.73
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4,410.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,565.95
|
| Rate for Payer: Heritage Provider Network Transplant |
$2,565.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2,534.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$2,534.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,564.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,922.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,981.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,564.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,411.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,971.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,096.57
|
| Rate for Payer: Multiplan Commercial |
$4,704.98
|
| Rate for Payer: Networks By Design Commercial |
$2,940.61
|
| Rate for Payer: Prime Health Services Commercial |
$4,999.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,528.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,528.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,940.61
|
| Rate for Payer: United Healthcare All Other HMO |
$2,940.61
|
| Rate for Payer: United Healthcare HMO Rider |
$2,940.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,940.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,346.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,721.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1,564.60
|
|
|
LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]
|
Facility
|
IP
|
$5,881.22
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
ERX21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,411.49 |
| Max. Negotiated Rate |
$4,999.04 |
| Rate for Payer: Blue Shield of California Commercial |
$4,187.43
|
| Rate for Payer: Blue Shield of California EPN |
$3,011.18
|
| Rate for Payer: Cash Price |
$2,646.55
|
| Rate for Payer: Cigna of CA HMO |
$4,116.85
|
| Rate for Payer: Cigna of CA PPO |
$4,116.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,352.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,352.49
|
| Rate for Payer: Galaxy Health WC |
$4,999.04
|
| Rate for Payer: Global Benefits Group Commercial |
$3,528.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,922.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,240.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,411.49
|
| Rate for Payer: Multiplan Commercial |
$4,704.98
|
| Rate for Payer: Networks By Design Commercial |
$2,940.61
|
| Rate for Payer: Prime Health Services Commercial |
$4,999.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,220.75
|
| Rate for Payer: United Healthcare All Other HMO |
$2,168.99
|
| Rate for Payer: United Healthcare HMO Rider |
$2,121.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,940.80
|
|
