|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-21
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$2.63
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO |
$3.59
|
| Rate for Payer: Cigna of CA PPO |
$3.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$4.10
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-11
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.06
|
| Rate for Payer: Blue Distinction Transplant |
$3.08
|
| Rate for Payer: Blue Shield of California Commercial |
$3.78
|
| Rate for Payer: Blue Shield of California EPN |
$3.00
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO |
$3.59
|
| Rate for Payer: Cigna of CA PPO |
$3.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.36
|
| Rate for Payer: Dignity Health Media |
$4.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$4.10
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.56
|
| Rate for Payer: United Healthcare All Other HMO |
$2.56
|
| Rate for Payer: United Healthcare HMO Rider |
$2.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.36
|
| Rate for Payer: Vantage Medical Group Senior |
$4.36
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$56.75
|
|
|
Service Code
|
NDC 63402-304-30
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.62 |
| Max. Negotiated Rate |
$48.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$37.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$48.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.81
|
| Rate for Payer: Blue Distinction Transplant |
$34.05
|
| Rate for Payer: Blue Shield of California Commercial |
$41.82
|
| Rate for Payer: Blue Shield of California EPN |
$33.14
|
| Rate for Payer: Cash Price |
$25.54
|
| Rate for Payer: Cigna of CA HMO |
$39.72
|
| Rate for Payer: Cigna of CA PPO |
$39.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.24
|
| Rate for Payer: Dignity Health Media |
$48.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$22.70
|
| Rate for Payer: Galaxy Health WC |
$48.24
|
| Rate for Payer: Global Benefits Group Commercial |
$34.05
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$42.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.62
|
| Rate for Payer: Multiplan Commercial |
$45.40
|
| Rate for Payer: Networks By Design Commercial |
$36.89
|
| Rate for Payer: Prime Health Services Commercial |
$48.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$34.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$34.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$28.38
|
| Rate for Payer: United Healthcare All Other HMO |
$28.38
|
| Rate for Payer: United Healthcare HMO Rider |
$28.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$48.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.24
|
| Rate for Payer: Vantage Medical Group Senior |
$48.24
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 47335-684-83
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-21
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.06
|
| Rate for Payer: Blue Distinction Transplant |
$3.08
|
| Rate for Payer: Blue Shield of California Commercial |
$3.78
|
| Rate for Payer: Blue Shield of California EPN |
$3.00
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO |
$3.59
|
| Rate for Payer: Cigna of CA PPO |
$3.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.36
|
| Rate for Payer: Dignity Health Media |
$4.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$4.10
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.56
|
| Rate for Payer: United Healthcare All Other HMO |
$2.56
|
| Rate for Payer: United Healthcare HMO Rider |
$2.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.36
|
| Rate for Payer: Vantage Medical Group Senior |
$4.36
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 47335-684-83
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.27
|
| Rate for Payer: Blue Distinction Transplant |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.81
|
| Rate for Payer: Dignity Health Media |
$1.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.06
|
| Rate for Payer: United Healthcare All Other HMO |
$1.06
|
| Rate for Payer: United Healthcare HMO Rider |
$1.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$56.75
|
|
|
Service Code
|
NDC 63402-304-30
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.62 |
| Max. Negotiated Rate |
$48.24 |
| Rate for Payer: Blue Shield of California Commercial |
$40.41
|
| Rate for Payer: Blue Shield of California EPN |
$29.06
|
| Rate for Payer: Cash Price |
$25.54
|
| Rate for Payer: Cigna of CA HMO |
$39.72
|
| Rate for Payer: Cigna of CA PPO |
$39.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.70
|
| Rate for Payer: Galaxy Health WC |
$48.24
|
| Rate for Payer: Global Benefits Group Commercial |
$34.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.62
|
| Rate for Payer: Multiplan Commercial |
$45.40
|
| Rate for Payer: Networks By Design Commercial |
$36.89
|
| Rate for Payer: Prime Health Services Commercial |
$48.24
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-11
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$2.63
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO |
$3.59
|
| Rate for Payer: Cigna of CA PPO |
$3.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$4.10
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
|
|
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [228261]
|
Facility
|
IP
|
$9,396.00
|
|
|
Service Code
|
NDC 68727-712-01
|
| Hospital Charge Code |
ERX408205864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,255.04 |
| Max. Negotiated Rate |
$7,986.60 |
| Rate for Payer: Blue Shield of California Commercial |
$6,689.95
|
| Rate for Payer: Blue Shield of California EPN |
$4,810.75
|
| Rate for Payer: Cash Price |
$4,228.20
|
| Rate for Payer: Cigna of CA HMO |
$6,577.20
|
| Rate for Payer: Cigna of CA PPO |
$6,577.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,758.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,758.40
|
| Rate for Payer: Galaxy Health WC |
$7,986.60
|
| Rate for Payer: Global Benefits Group Commercial |
$5,637.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6,267.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,579.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,255.04
|
| Rate for Payer: Multiplan Commercial |
$7,516.80
|
| Rate for Payer: Networks By Design Commercial |
$4,698.00
|
| Rate for Payer: Prime Health Services Commercial |
$7,986.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,547.93
|
| Rate for Payer: United Healthcare All Other HMO |
$3,465.24
|
| Rate for Payer: United Healthcare HMO Rider |
$3,390.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,100.68
|
|
|
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [228261]
|
Facility
|
OP
|
$9,396.00
|
|
|
Service Code
|
NDC 68727-712-01
|
| Hospital Charge Code |
ERX408205864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,255.04 |
| Max. Negotiated Rate |
$7,986.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6,162.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,986.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,167.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,167.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,598.14
|
| Rate for Payer: Blue Distinction Transplant |
$5,637.60
|
| Rate for Payer: Blue Shield of California Commercial |
$6,924.85
|
| Rate for Payer: Blue Shield of California EPN |
$5,487.26
|
| Rate for Payer: Cash Price |
$4,228.20
|
| Rate for Payer: Cigna of CA HMO |
$6,577.20
|
| Rate for Payer: Cigna of CA PPO |
$6,577.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,986.60
|
| Rate for Payer: Dignity Health Media |
$7,986.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,986.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,758.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,758.40
|
| Rate for Payer: Galaxy Health WC |
$7,986.60
|
| Rate for Payer: Global Benefits Group Commercial |
$5,637.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$7,047.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6,267.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,579.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,255.04
|
| Rate for Payer: Multiplan Commercial |
$7,516.80
|
| Rate for Payer: Networks By Design Commercial |
$4,698.00
|
| Rate for Payer: Prime Health Services Commercial |
$7,986.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5,637.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5,637.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,698.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4,698.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,698.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,698.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,986.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,986.60
|
| Rate for Payer: Vantage Medical Group Senior |
$7,986.60
|
|
|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [225877]
|
Facility
|
OP
|
$4,559.88
|
|
|
Service Code
|
CPT J0896
|
| Hospital Charge Code |
ERX225877
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.97 |
| Max. Negotiated Rate |
$3,875.90 |
| Rate for Payer: Aetna of CA HMO/PPO |
$251.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$49.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$43.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$43.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.44
|
| Rate for Payer: Blue Distinction Transplant |
$2,735.93
|
| Rate for Payer: Blue Shield of California Commercial |
$3,360.63
|
| Rate for Payer: Blue Shield of California EPN |
$41.29
|
| Rate for Payer: Cash Price |
$2,051.95
|
| Rate for Payer: Cash Price |
$2,051.95
|
| Rate for Payer: Cigna of CA HMO |
$3,191.92
|
| Rate for Payer: Cigna of CA PPO |
$3,191.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.96
|
| Rate for Payer: Dignity Health Media |
$43.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$39.97
|
| Rate for Payer: EPIC Health Plan Transplant |
$39.97
|
| Rate for Payer: Galaxy Health WC |
$3,875.90
|
| Rate for Payer: Global Benefits Group Commercial |
$2,735.93
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3,419.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.55
|
| Rate for Payer: Heritage Provider Network Transplant |
$65.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$64.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$64.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$39.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,041.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$39.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,094.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$50.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$53.56
|
| Rate for Payer: Multiplan Commercial |
$3,647.90
|
| Rate for Payer: Networks By Design Commercial |
$2,279.94
|
| Rate for Payer: Prime Health Services Commercial |
$3,875.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,735.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,735.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,279.94
|
| Rate for Payer: United Healthcare All Other HMO |
$2,279.94
|
| Rate for Payer: United Healthcare HMO Rider |
$2,279.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,279.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$49.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.97
|
| Rate for Payer: Vantage Medical Group Senior |
$43.97
|
|
|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [225877]
|
Facility
|
IP
|
$4,559.88
|
|
|
Service Code
|
CPT J0896
|
| Hospital Charge Code |
ERX225877
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,094.37 |
| Max. Negotiated Rate |
$3,875.90 |
| Rate for Payer: Blue Shield of California Commercial |
$3,246.63
|
| Rate for Payer: Blue Shield of California EPN |
$2,334.66
|
| Rate for Payer: Cash Price |
$2,051.95
|
| Rate for Payer: Cigna of CA HMO |
$3,191.92
|
| Rate for Payer: Cigna of CA PPO |
$3,191.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,823.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,823.95
|
| Rate for Payer: Galaxy Health WC |
$3,875.90
|
| Rate for Payer: Global Benefits Group Commercial |
$2,735.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,041.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,737.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,094.37
|
| Rate for Payer: Multiplan Commercial |
$3,647.90
|
| Rate for Payer: Networks By Design Commercial |
$2,279.94
|
| Rate for Payer: Prime Health Services Commercial |
$3,875.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,721.81
|
| Rate for Payer: United Healthcare All Other HMO |
$1,681.68
|
| Rate for Payer: United Healthcare HMO Rider |
$1,645.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,504.76
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [225879]
|
Facility
|
IP
|
$13,679.62
|
|
|
Service Code
|
CPT J0896
|
| Hospital Charge Code |
ERX225879
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,283.11 |
| Max. Negotiated Rate |
$11,627.68 |
| Rate for Payer: Blue Shield of California Commercial |
$9,739.89
|
| Rate for Payer: Blue Shield of California EPN |
$7,003.97
|
| Rate for Payer: Cash Price |
$6,155.83
|
| Rate for Payer: Cigna of CA HMO |
$9,575.73
|
| Rate for Payer: Cigna of CA PPO |
$9,575.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,471.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$5,471.85
|
| Rate for Payer: Galaxy Health WC |
$11,627.68
|
| Rate for Payer: Global Benefits Group Commercial |
$8,207.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9,124.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,211.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,283.11
|
| Rate for Payer: Multiplan Commercial |
$10,943.70
|
| Rate for Payer: Networks By Design Commercial |
$6,839.81
|
| Rate for Payer: Prime Health Services Commercial |
$11,627.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,165.42
|
| Rate for Payer: United Healthcare All Other HMO |
$5,045.04
|
| Rate for Payer: United Healthcare HMO Rider |
$4,935.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,514.27
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [225879]
|
Facility
|
OP
|
$13,679.62
|
|
|
Service Code
|
CPT J0896
|
| Hospital Charge Code |
ERX225879
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.97 |
| Max. Negotiated Rate |
$11,627.68 |
| Rate for Payer: Aetna of CA HMO/PPO |
$251.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$49.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$43.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$43.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.44
|
| Rate for Payer: Blue Distinction Transplant |
$8,207.77
|
| Rate for Payer: Blue Shield of California Commercial |
$10,081.88
|
| Rate for Payer: Blue Shield of California EPN |
$41.29
|
| Rate for Payer: Cash Price |
$6,155.83
|
| Rate for Payer: Cash Price |
$6,155.83
|
| Rate for Payer: Cigna of CA HMO |
$9,575.73
|
| Rate for Payer: Cigna of CA PPO |
$9,575.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.96
|
| Rate for Payer: Dignity Health Media |
$43.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$39.97
|
| Rate for Payer: EPIC Health Plan Transplant |
$39.97
|
| Rate for Payer: Galaxy Health WC |
$11,627.68
|
| Rate for Payer: Global Benefits Group Commercial |
$8,207.77
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$10,259.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.55
|
| Rate for Payer: Heritage Provider Network Transplant |
$65.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$64.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$64.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$39.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9,124.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$39.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,283.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$50.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$53.56
|
| Rate for Payer: Multiplan Commercial |
$10,943.70
|
| Rate for Payer: Networks By Design Commercial |
$6,839.81
|
| Rate for Payer: Prime Health Services Commercial |
$11,627.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8,207.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8,207.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$6,839.81
|
| Rate for Payer: United Healthcare All Other HMO |
$6,839.81
|
| Rate for Payer: United Healthcare HMO Rider |
$6,839.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,839.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$49.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.97
|
| Rate for Payer: Vantage Medical Group Senior |
$43.97
|
|
|
LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [220890]
|
Facility
|
OP
|
$58,680.00
|
|
|
Service Code
|
CPT A9513
|
| Hospital Charge Code |
ERX220890
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$380.87 |
| Max. Negotiated Rate |
$49,878.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$542.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$571.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$418.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$380.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$506.23
|
| Rate for Payer: Blue Distinction Transplant |
$35,208.00
|
| Rate for Payer: Blue Shield of California Commercial |
$34,679.88
|
| Rate for Payer: Blue Shield of California EPN |
$27,520.92
|
| Rate for Payer: Cash Price |
$26,406.00
|
| Rate for Payer: Cash Price |
$26,406.00
|
| Rate for Payer: Cigna of CA HMO |
$37,555.20
|
| Rate for Payer: Cigna of CA PPO |
$43,423.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$571.30
|
| Rate for Payer: Dignity Health Media |
$380.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$418.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$514.17
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$380.87
|
| Rate for Payer: EPIC Health Plan Transplant |
$380.87
|
| Rate for Payer: Galaxy Health WC |
$49,878.00
|
| Rate for Payer: Global Benefits Group Commercial |
$35,208.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$44,010.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$624.63
|
| Rate for Payer: Heritage Provider Network Transplant |
$624.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$617.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$617.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$380.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39,139.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$529.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$380.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14,083.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$479.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$510.37
|
| Rate for Payer: Multiplan Commercial |
$46,944.00
|
| Rate for Payer: Networks By Design Commercial |
$38,142.00
|
| Rate for Payer: Prime Health Services Commercial |
$49,878.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35,208.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35,208.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$29,340.00
|
| Rate for Payer: United Healthcare All Other HMO |
$29,340.00
|
| Rate for Payer: United Healthcare HMO Rider |
$29,340.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29,340.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$571.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$418.96
|
| Rate for Payer: Vantage Medical Group Senior |
$380.87
|
|
|
LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [220890]
|
Facility
|
IP
|
$58,680.00
|
|
|
Service Code
|
CPT A9513
|
| Hospital Charge Code |
ERX220890
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$14,083.20 |
| Max. Negotiated Rate |
$49,878.00 |
| Rate for Payer: Blue Shield of California Commercial |
$41,780.16
|
| Rate for Payer: Blue Shield of California EPN |
$30,044.16
|
| Rate for Payer: Cash Price |
$26,406.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$23,472.00
|
| Rate for Payer: Galaxy Health WC |
$49,878.00
|
| Rate for Payer: Global Benefits Group Commercial |
$35,208.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39,139.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22,357.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14,083.20
|
| Rate for Payer: Multiplan Commercial |
$46,944.00
|
| Rate for Payer: Networks By Design Commercial |
$38,142.00
|
| Rate for Payer: Prime Health Services Commercial |
$49,878.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$22,157.57
|
| Rate for Payer: United Healthcare All Other HMO |
$21,641.18
|
| Rate for Payer: United Healthcare HMO Rider |
$21,171.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19,364.40
|
|
|
LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [233901]
|
Facility
|
IP
|
$52,020.00
|
|
|
Service Code
|
CPT A9607
|
| Hospital Charge Code |
NDG233901
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$12,484.80 |
| Max. Negotiated Rate |
$44,217.00 |
| Rate for Payer: Blue Shield of California Commercial |
$37,038.24
|
| Rate for Payer: Blue Shield of California EPN |
$26,634.24
|
| Rate for Payer: Cash Price |
$23,409.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$20,808.00
|
| Rate for Payer: Galaxy Health WC |
$44,217.00
|
| Rate for Payer: Global Benefits Group Commercial |
$31,212.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34,697.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19,819.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12,484.80
|
| Rate for Payer: Multiplan Commercial |
$41,616.00
|
| Rate for Payer: Networks By Design Commercial |
$33,813.00
|
| Rate for Payer: Prime Health Services Commercial |
$44,217.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$19,642.75
|
| Rate for Payer: United Healthcare All Other HMO |
$19,184.98
|
| Rate for Payer: United Healthcare HMO Rider |
$18,768.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17,166.60
|
|
|
LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [233901]
|
Facility
|
OP
|
$52,020.00
|
|
|
Service Code
|
CPT A9607
|
| Hospital Charge Code |
NDG233901
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$229.76 |
| Max. Negotiated Rate |
$44,217.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,575.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$344.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$252.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$229.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$452.94
|
| Rate for Payer: Blue Distinction Transplant |
$31,212.00
|
| Rate for Payer: Blue Shield of California Commercial |
$30,743.82
|
| Rate for Payer: Blue Shield of California EPN |
$24,397.38
|
| Rate for Payer: Cash Price |
$23,409.00
|
| Rate for Payer: Cash Price |
$23,409.00
|
| Rate for Payer: Cigna of CA HMO |
$33,292.80
|
| Rate for Payer: Cigna of CA PPO |
$38,494.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$287.19
|
| Rate for Payer: Dignity Health Media |
$252.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$252.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$310.17
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$229.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$229.76
|
| Rate for Payer: Galaxy Health WC |
$44,217.00
|
| Rate for Payer: Global Benefits Group Commercial |
$31,212.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$39,015.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$376.80
|
| Rate for Payer: Heritage Provider Network Transplant |
$376.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$372.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$372.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$229.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34,697.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$411.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$229.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12,484.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$289.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$307.87
|
| Rate for Payer: Multiplan Commercial |
$41,616.00
|
| Rate for Payer: Networks By Design Commercial |
$33,813.00
|
| Rate for Payer: Prime Health Services Commercial |
$44,217.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$31,212.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$31,212.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$26,010.00
|
| Rate for Payer: United Healthcare All Other HMO |
$26,010.00
|
| Rate for Payer: United Healthcare HMO Rider |
$26,010.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$26,010.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$287.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$252.73
|
| Rate for Payer: Vantage Medical Group Senior |
$252.73
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
|
IP
|
$17,665.44
|
|
|
Service Code
|
APR-DRG 6943
|
| Min. Negotiated Rate |
$13,551.25 |
| Max. Negotiated Rate |
$17,665.44 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,551.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,665.44
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
|
IP
|
$30,514.15
|
|
|
Service Code
|
APR-DRG 6944
|
| Min. Negotiated Rate |
$23,407.57 |
| Max. Negotiated Rate |
$30,514.15 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23,407.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30,514.15
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
|
IP
|
$9,605.05
|
|
|
Service Code
|
APR-DRG 6941
|
| Min. Negotiated Rate |
$7,368.09 |
| Max. Negotiated Rate |
$9,605.05 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,368.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,605.05
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
|
IP
|
$12,020.52
|
|
|
Service Code
|
APR-DRG 6942
|
| Min. Negotiated Rate |
$9,221.00 |
| Max. Negotiated Rate |
$12,020.52 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,221.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,020.52
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
|
IP
|
$26,431.64
|
|
|
Service Code
|
APR-DRG 6913
|
| Min. Negotiated Rate |
$20,275.85 |
| Max. Negotiated Rate |
$26,431.64 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20,275.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26,431.64
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
|
IP
|
$49,174.51
|
|
|
Service Code
|
APR-DRG 6914
|
| Min. Negotiated Rate |
$37,722.02 |
| Max. Negotiated Rate |
$49,174.51 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$37,722.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49,174.51
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
|
IP
|
$13,613.08
|
|
|
Service Code
|
APR-DRG 6911
|
| Min. Negotiated Rate |
$10,442.67 |
| Max. Negotiated Rate |
$13,613.08 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,442.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,613.08
|
|
