|
LARONIDASE 2.9 MG/5 ML INTRAVENOUS SOLUTION [35779]
|
Facility
OP
|
$247.05
|
|
|
Service Code
|
CPT J1931
|
| Hospital Charge Code |
1753490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.44 |
| Max. Negotiated Rate |
$235.51 |
| Rate for Payer: Aetna of CA HMO/PPO |
$235.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$46.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$41.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$41.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$47.66
|
| Rate for Payer: BCBS Transplant Transplant |
$148.23
|
| Rate for Payer: Blue Shield of California Commercial |
$182.08
|
| Rate for Payer: Blue Shield of California EPN |
$37.51
|
| Rate for Payer: Cash Price |
$111.17
|
| Rate for Payer: Cash Price |
$111.17
|
| Rate for Payer: Cigna of CA HMO |
$172.94
|
| Rate for Payer: Cigna of CA PPO |
$172.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$56.16
|
| Rate for Payer: Dignity Health Media |
$37.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$41.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.55
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$37.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$37.44
|
| Rate for Payer: Galaxy Health WC |
$209.99
|
| Rate for Payer: Global Benefits Group Commercial |
$148.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$185.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.40
|
| Rate for Payer: Heritage Provider Network Transplant |
$61.40
|
| Rate for Payer: IEHP Medi-Cal |
$60.65
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$60.65
|
| Rate for Payer: IEHP Medicare Advantage |
$37.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$164.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$79.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$37.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$47.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$50.17
|
| Rate for Payer: Multiplan Commercial |
$197.64
|
| Rate for Payer: Networks By Design Commercial |
$123.52
|
| Rate for Payer: Prime Health Services Commercial |
$209.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$148.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$148.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$123.52
|
| Rate for Payer: United Healthcare All Other HMO |
$123.52
|
| Rate for Payer: United Healthcare HMO Rider |
$123.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$123.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$56.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$41.19
|
| Rate for Payer: Vantage Medical Group Senior |
$37.44
|
|
|
LARONIDASE 2.9 MG/5 ML INTRAVENOUS SOLUTION [35779]
|
Facility
IP
|
$247.05
|
|
|
Service Code
|
CPT J1931
|
| Hospital Charge Code |
1753490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.29 |
| Max. Negotiated Rate |
$209.99 |
| Rate for Payer: Blue Shield of California Commercial |
$175.90
|
| Rate for Payer: Blue Shield of California EPN |
$126.49
|
| Rate for Payer: Cash Price |
$111.17
|
| Rate for Payer: Cigna of CA HMO |
$172.94
|
| Rate for Payer: Cigna of CA PPO |
$172.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$98.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$98.82
|
| Rate for Payer: Galaxy Health WC |
$209.99
|
| Rate for Payer: Global Benefits Group Commercial |
$148.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$164.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$94.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.29
|
| Rate for Payer: Multiplan Commercial |
$197.64
|
| Rate for Payer: Networks By Design Commercial |
$123.52
|
| Rate for Payer: Prime Health Services Commercial |
$209.99
|
|
|
Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope
|
Facility
OP
|
$12,491.00
|
|
|
Service Code
|
CPT 31541
|
| Min. Negotiated Rate |
$509.31 |
| Max. Negotiated Rate |
$12,491.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12,491.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,018.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5,146.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,678.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,282.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,018.40
|
| Rate for Payer: Dignity Health Media |
$4,678.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,146.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,316.56
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,678.93
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,678.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,673.45
|
| Rate for Payer: Heritage Provider Network Transplant |
$7,673.45
|
| Rate for Payer: IEHP Medi-Cal |
$7,579.87
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$7,579.87
|
| Rate for Payer: IEHP Medicare Advantage |
$4,678.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$509.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,678.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,895.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,269.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,018.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,146.82
|
| Rate for Payer: Vantage Medical Group Senior |
$4,678.93
|
|
|
Laryngoscopy, direct, operative, with foreign body removal;
|
Facility
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 31530
|
| Min. Negotiated Rate |
$424.42 |
| Max. Negotiated Rate |
$7,385.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7,385.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,180.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,332.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,120.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,938.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,180.93
|
| Rate for Payer: Dignity Health Media |
$2,120.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,332.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,862.84
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,120.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,120.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,477.82
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,477.82
|
| Rate for Payer: IEHP Medi-Cal |
$3,435.40
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$3,435.40
|
| Rate for Payer: IEHP Medicare Advantage |
$2,120.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$424.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,120.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,671.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,841.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,180.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,332.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2,120.62
|
|
|
Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or telescope
|
Facility
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 31526
|
| Min. Negotiated Rate |
$262.43 |
| Max. Negotiated Rate |
$7,385.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7,385.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,180.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,332.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,120.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,938.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,180.93
|
| Rate for Payer: Dignity Health Media |
$2,120.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,332.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,862.84
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,120.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,120.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,477.82
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,477.82
|
| Rate for Payer: IEHP Medi-Cal |
$3,435.40
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$3,435.40
|
| Rate for Payer: IEHP Medicare Advantage |
$2,120.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,120.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,671.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,841.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,180.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,332.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2,120.62
|
|
|
Laryngoscopy, flexible; with removal of foreign body(s)
|
Facility
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 31577
|
| Min. Negotiated Rate |
$288.61 |
| Max. Negotiated Rate |
$7,385.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7,385.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$765.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$561.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$510.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,984.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$765.27
|
| Rate for Payer: Dignity Health Media |
$510.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$561.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$688.74
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$510.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$510.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$836.70
|
| Rate for Payer: Heritage Provider Network Transplant |
$836.70
|
| Rate for Payer: IEHP Medi-Cal |
$826.49
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$826.49
|
| Rate for Payer: IEHP Medicare Advantage |
$510.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$288.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$510.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$642.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$683.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$765.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$561.20
|
| Rate for Payer: Vantage Medical Group Senior |
$510.18
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
OP
|
$2.38
|
|
|
Service Code
|
NDC 70069-421-01
|
| Hospital Charge Code |
1740302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.42
|
| Rate for Payer: BCBS Transplant Transplant |
$1.43
|
| Rate for Payer: Blue Shield of California Commercial |
$1.75
|
| Rate for Payer: Blue Shield of California EPN |
$1.39
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.02
|
| Rate for Payer: Dignity Health Media |
$2.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.02
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.02
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.19
|
| Rate for Payer: United Healthcare All Other HMO |
$1.19
|
| Rate for Payer: United Healthcare HMO Rider |
$1.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.02
|
| Rate for Payer: Vantage Medical Group Senior |
$2.02
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
OP
|
$5.14
|
|
|
Service Code
|
NDC 61314-547-01
|
| Hospital Charge Code |
1740302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: BCBS Transplant Transplant |
$3.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.06
|
| Rate for Payer: Blue Shield of California Commercial |
$3.79
|
| Rate for Payer: Blue Shield of California EPN |
$3.00
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO |
$3.60
|
| Rate for Payer: Cigna of CA PPO |
$3.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.37
|
| Rate for Payer: Dignity Health Media |
$4.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.06
|
| Rate for Payer: Galaxy Health WC |
$4.37
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$4.11
|
| Rate for Payer: Networks By Design Commercial |
$3.34
|
| Rate for Payer: Prime Health Services Commercial |
$4.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.08
|
| 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 |
$2.57
|
| Rate for Payer: United Healthcare All Other HMO |
$2.57
|
| Rate for Payer: United Healthcare HMO Rider |
$2.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.37
|
| Rate for Payer: Vantage Medical Group Senior |
$4.37
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
IP
|
$2.38
|
|
|
Service Code
|
NDC 70069-421-01
|
| Hospital Charge Code |
1740302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Blue Shield of California Commercial |
$1.69
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.02
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.02
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
IP
|
$5.14
|
|
|
Service Code
|
NDC 61314-547-01
|
| Hospital Charge Code |
1740302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Blue Shield of California Commercial |
$3.66
|
| Rate for Payer: Blue Shield of California EPN |
$2.63
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO |
$3.60
|
| Rate for Payer: Cigna of CA PPO |
$3.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.06
|
| Rate for Payer: Galaxy Health WC |
$4.37
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$4.11
|
| Rate for Payer: Networks By Design Commercial |
$3.34
|
| Rate for Payer: Prime Health Services Commercial |
$4.37
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
IP
|
$3.20
|
|
|
Service Code
|
NDC 60505-2502-1
|
| Hospital Charge Code |
1712456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Blue Shield of California Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.64
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
OP
|
$1.31
|
|
|
Service Code
|
NDC 70710-1157-3
|
| Hospital Charge Code |
1712456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.78
|
| Rate for Payer: BCBS Transplant Transplant |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Media |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.52
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare HMO Rider |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
OP
|
$3.20
|
|
|
Service Code
|
NDC 60505-2502-1
|
| Hospital Charge Code |
1712456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.91
|
| Rate for Payer: BCBS Transplant Transplant |
$1.92
|
| Rate for Payer: Blue Shield of California Commercial |
$2.36
|
| Rate for Payer: Blue Shield of California EPN |
$1.87
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Media |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.60
|
| Rate for Payer: United Healthcare All Other HMO |
$1.60
|
| Rate for Payer: United Healthcare HMO Rider |
$1.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
IP
|
$1.31
|
|
|
Service Code
|
NDC 70710-1157-3
|
| Hospital Charge Code |
1712456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
OP
|
$3.32
|
|
|
Service Code
|
NDC 60505-2503-1
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.98
|
| Rate for Payer: BCBS Transplant Transplant |
$1.99
|
| Rate for Payer: Blue Shield of California Commercial |
$2.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.94
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.82
|
| Rate for Payer: Dignity Health Media |
$2.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.66
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.66
|
| Rate for Payer: United Healthcare All Other HMO |
$1.66
|
| Rate for Payer: United Healthcare HMO Rider |
$1.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Vantage Medical Group Senior |
$2.82
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
IP
|
$6.00
|
|
|
Service Code
|
NDC 62332-062-30
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Blue Shield of California Commercial |
$4.27
|
| Rate for Payer: Blue Shield of California EPN |
$3.07
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
OP
|
$6.00
|
|
|
Service Code
|
NDC 62332-062-30
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.57
|
| Rate for Payer: BCBS Transplant Transplant |
$3.60
|
| Rate for Payer: Blue Shield of California Commercial |
$4.42
|
| Rate for Payer: Blue Shield of California EPN |
$3.50
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Media |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.00
|
| Rate for Payer: United Healthcare All Other HMO |
$3.00
|
| Rate for Payer: United Healthcare HMO Rider |
$3.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
IP
|
$3.32
|
|
|
Service Code
|
NDC 60505-2503-1
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Blue Shield of California Commercial |
$2.36
|
| Rate for Payer: Blue Shield of California EPN |
$1.70
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.66
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
OP
|
$0.88
|
|
|
Service Code
|
NDC 23155-044-03
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.52
|
| Rate for Payer: BCBS Transplant Transplant |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.75
|
| Rate for Payer: Dignity Health Media |
$0.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.75
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.75
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
IP
|
$0.88
|
|
|
Service Code
|
NDC 23155-044-03
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.75
|
|
|
Lengthening or shortening of tendon, leg or ankle; multiple tendons (through same incision), each
|
Facility
OP
|
$9,590.00
|
|
|
Service Code
|
CPT 27686
|
| Min. Negotiated Rate |
$560.94 |
| Max. Negotiated Rate |
$9,590.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9,590.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,938.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Media |
$4,044.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,459.68
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,044.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,632.50
|
| Rate for Payer: Heritage Provider Network Transplant |
$6,632.50
|
| Rate for Payer: IEHP Medi-Cal |
$6,551.62
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$6,551.62
|
| Rate for Payer: IEHP Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$560.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,044.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,419.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
Lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure)
|
Facility
OP
|
$9,590.00
|
|
|
Service Code
|
CPT 27685
|
| Min. Negotiated Rate |
$560.94 |
| Max. Negotiated Rate |
$9,590.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9,590.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,282.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Media |
$4,044.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,459.68
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,044.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,632.50
|
| Rate for Payer: Heritage Provider Network Transplant |
$6,632.50
|
| Rate for Payer: IEHP Medi-Cal |
$6,551.62
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$6,551.62
|
| Rate for Payer: IEHP Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$560.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,044.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,419.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
IP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-02
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.13 |
| Max. Negotiated Rate |
$14.64 |
| Rate for Payer: Blue Shield of California Commercial |
$12.26
|
| Rate for Payer: Blue Shield of California EPN |
$8.82
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.89
|
| Rate for Payer: Galaxy Health WC |
$14.64
|
| Rate for Payer: Global Benefits Group Commercial |
$10.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.13
|
| Rate for Payer: Multiplan Commercial |
$13.78
|
| Rate for Payer: Networks By Design Commercial |
$11.19
|
| Rate for Payer: Prime Health Services Commercial |
$14.64
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
OP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-01
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.13 |
| Max. Negotiated Rate |
$14.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.26
|
| Rate for Payer: BCBS Transplant Transplant |
$10.33
|
| Rate for Payer: Blue Shield of California Commercial |
$12.69
|
| Rate for Payer: Blue Shield of California EPN |
$10.06
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: Cigna of CA HMO |
$11.02
|
| Rate for Payer: Cigna of CA PPO |
$12.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.64
|
| Rate for Payer: Dignity Health Media |
$14.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.89
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.89
|
| Rate for Payer: Galaxy Health WC |
$14.64
|
| Rate for Payer: Global Benefits Group Commercial |
$10.33
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$12.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.13
|
| Rate for Payer: Multiplan Commercial |
$13.78
|
| Rate for Payer: Networks By Design Commercial |
$11.19
|
| Rate for Payer: Prime Health Services Commercial |
$14.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.61
|
| Rate for Payer: United Healthcare All Other HMO |
$8.61
|
| Rate for Payer: United Healthcare HMO Rider |
$8.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.64
|
| Rate for Payer: Vantage Medical Group Senior |
$14.64
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
OP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-02
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.13 |
| Max. Negotiated Rate |
$14.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.26
|
| Rate for Payer: BCBS Transplant Transplant |
$10.33
|
| Rate for Payer: Blue Shield of California Commercial |
$12.69
|
| Rate for Payer: Blue Shield of California EPN |
$10.06
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: Cigna of CA HMO |
$11.02
|
| Rate for Payer: Cigna of CA PPO |
$12.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.64
|
| Rate for Payer: Dignity Health Media |
$14.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.89
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.89
|
| Rate for Payer: Galaxy Health WC |
$14.64
|
| Rate for Payer: Global Benefits Group Commercial |
$10.33
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$12.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.13
|
| Rate for Payer: Multiplan Commercial |
$13.78
|
| Rate for Payer: Networks By Design Commercial |
$11.19
|
| Rate for Payer: Prime Health Services Commercial |
$14.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.61
|
| Rate for Payer: United Healthcare All Other HMO |
$8.61
|
| Rate for Payer: United Healthcare HMO Rider |
$8.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.64
|
| Rate for Payer: Vantage Medical Group Senior |
$14.64
|
|
