|
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 |
$72.40
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| 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 |
$48.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.37
|
| Rate for Payer: Galaxy Health WC |
$87.92
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Global Benefits Group Commercial |
$62.06
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.41
|
| 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 |
$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 |
$87.92
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$87.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$56.89
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$66.00
|
| Rate for Payer: AlphaCare 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: BCBS Transplant Transplant |
$62.06
|
| Rate for Payer: BCBS Transplant 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 |
$46.54
|
| 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: Dignity Health Commercial/Exchange |
$102.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.92
|
| Rate for Payer: Dignity Health Media |
$87.92
|
| Rate for Payer: Dignity Health Media |
$102.00
|
| 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 |
$41.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.00
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Galaxy Health WC |
$87.92
|
| Rate for Payer: Global Benefits Group Commercial |
$62.06
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$90.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant 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 |
$87.92
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
| 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 |
$60.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$51.72
|
| Rate for Payer: United Healthcare All Other HMO |
$51.72
|
| Rate for Payer: United Healthcare All Other HMO |
$60.00
|
| Rate for Payer: United Healthcare HMO Rider |
$51.72
|
| Rate for Payer: United Healthcare HMO Rider |
$60.00
|
| 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 |
$102.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$87.92
|
| 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 |
$87.92
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
IP
|
$6.34
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Blue Shield of California Commercial |
$4.51
|
| Rate for Payer: Blue Shield of California Commercial |
$8.54
|
| Rate for Payer: Blue Shield of California EPN |
$3.25
|
| Rate for Payer: Blue Shield of California EPN |
$6.14
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna of CA HMO |
$4.44
|
| Rate for Payer: Cigna of CA HMO |
$8.40
|
| 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 |
$4.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| 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 |
$2.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.57
|
| 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 |
$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 |
$10.20
|
| Rate for Payer: Prime Health Services Commercial |
$5.39
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.49
|
| Rate for Payer: AlphaCare 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: BCBS Transplant Transplant |
$3.80
|
| Rate for Payer: BCBS Transplant Transplant |
$7.20
|
| Rate for Payer: Blue Shield of California Commercial |
$4.67
|
| Rate for Payer: Blue Shield of California Commercial |
$8.84
|
| 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 |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cigna of CA HMO |
$4.44
|
| Rate for Payer: Cigna of CA HMO |
$8.40
|
| 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 |
$10.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.39
|
| Rate for Payer: Dignity Health Media |
$5.39
|
| Rate for Payer: Dignity Health Media |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.20
|
| 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 |
$2.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.80
|
| 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 Transplant Other |
$9.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.76
|
| 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 |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
| Rate for Payer: Multiplan Commercial |
$9.60
|
| Rate for Payer: Networks By Design Commercial |
$3.17
|
| Rate for Payer: Networks By Design Commercial |
$6.00
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
| Rate for Payer: Prime Health Services Commercial |
$5.39
|
| 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 |
$7.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.80
|
| 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 |
$6.00
|
| Rate for Payer: United Healthcare HMO Rider |
$3.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.00
|
| 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 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: Galaxy Health WC |
$1.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.13
|
| Rate for Payer: BCBS Transplant 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: Global Benefits Group Commercial |
$1.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$1.13
|
| 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
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
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
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: AlphaCare Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.80
|
| 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
|
$1.34
|
|
|
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
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: AlphaCare Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.80
|
| 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
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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$1,955.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,721.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,721.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$957.53
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: IEHP Medi-Cal |
$2,534.66
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$2,534.66
|
| Rate for Payer: 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 INTRAMUSCULAR KIT [10390]
|
Facility
IP
|
$4,281.55
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
1722009
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,027.57 |
| Max. Negotiated Rate |
$3,639.32 |
| Rate for Payer: Blue Shield of California Commercial |
$3,048.46
|
| Rate for Payer: Blue Shield of California EPN |
$2,192.15
|
| Rate for Payer: Cash Price |
$1,926.70
|
| Rate for Payer: Cigna of CA HMO |
$2,997.08
|
| Rate for Payer: Cigna of CA PPO |
$2,997.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,712.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,712.62
|
| Rate for Payer: Galaxy Health WC |
$3,639.32
|
| Rate for Payer: Global Benefits Group Commercial |
$2,568.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,855.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,631.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,027.57
|
| Rate for Payer: Multiplan Commercial |
$3,425.24
|
| Rate for Payer: Networks By Design Commercial |
$2,140.78
|
| Rate for Payer: Prime Health Services Commercial |
$3,639.32
|
|
|
LEUPROLIDE 11.25 MG INTRAMUSCULAR KIT [10390]
|
Facility
OP
|
$4,281.55
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
1722009
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$1,955.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,721.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,721.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$957.53
|
| Rate for Payer: BCBS Transplant Transplant |
$2,568.93
|
| Rate for Payer: Blue Shield of California Commercial |
$3,155.50
|
| Rate for Payer: Blue Shield of California EPN |
$1,675.92
|
| Rate for Payer: Cash Price |
$1,926.70
|
| Rate for Payer: Cash Price |
$1,926.70
|
| Rate for Payer: Cigna of CA HMO |
$2,997.08
|
| Rate for Payer: Cigna of CA PPO |
$2,997.08
|
| 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 |
$3,639.32
|
| Rate for Payer: Global Benefits Group Commercial |
$2,568.93
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3,211.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,565.95
|
| Rate for Payer: Heritage Provider Network Transplant |
$2,565.95
|
| Rate for Payer: IEHP Medi-Cal |
$2,534.66
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$2,534.66
|
| Rate for Payer: IEHP Medicare Advantage |
$1,564.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,855.79
|
| 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 |
$1,027.57
|
| 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 |
$3,425.24
|
| Rate for Payer: Networks By Design Commercial |
$2,140.78
|
| Rate for Payer: Prime Health Services Commercial |
$3,639.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,568.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,568.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,140.78
|
| Rate for Payer: United Healthcare All Other HMO |
$2,140.78
|
| Rate for Payer: United Healthcare HMO Rider |
$2,140.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,140.78
|
| 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 1 MG/0.2 ML SUBCUTANEOUS KIT [14135]
|
Facility
OP
|
$855.36
|
|
|
Service Code
|
CPT J9218
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.74 |
| Max. Negotiated Rate |
$727.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$183.60
|
| Rate for Payer: BCBS Transplant Transplant |
$513.22
|
| Rate for Payer: Blue Shield of California Commercial |
$630.40
|
| Rate for Payer: Blue Shield of California EPN |
$60.79
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cigna of CA HMO |
$598.75
|
| Rate for Payer: Cigna of CA PPO |
$598.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.62
|
| Rate for Payer: Dignity Health Media |
$13.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.56
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$13.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.74
|
| Rate for Payer: Galaxy Health WC |
$727.06
|
| Rate for Payer: Global Benefits Group Commercial |
$513.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$641.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.54
|
| Rate for Payer: Heritage Provider Network Transplant |
$22.54
|
| Rate for Payer: IEHP Medi-Cal |
$22.27
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$22.27
|
| Rate for Payer: IEHP Medicare Advantage |
$13.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$570.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$325.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$205.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.42
|
| Rate for Payer: Multiplan Commercial |
$684.29
|
| Rate for Payer: Networks By Design Commercial |
$427.68
|
| Rate for Payer: Prime Health Services Commercial |
$727.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$513.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$513.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$427.68
|
| Rate for Payer: United Healthcare All Other HMO |
$427.68
|
| Rate for Payer: United Healthcare HMO Rider |
$427.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$427.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: Vantage Medical Group Senior |
$13.74
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT [14135]
|
Facility
IP
|
$855.36
|
|
|
Service Code
|
CPT J9218
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$205.29 |
| Max. Negotiated Rate |
$727.06 |
| Rate for Payer: Blue Shield of California Commercial |
$609.02
|
| Rate for Payer: Blue Shield of California EPN |
$437.94
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cigna of CA HMO |
$598.75
|
| Rate for Payer: Cigna of CA PPO |
$598.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$342.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$342.14
|
| Rate for Payer: Galaxy Health WC |
$727.06
|
| Rate for Payer: Global Benefits Group Commercial |
$513.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$570.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$325.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$205.29
|
| Rate for Payer: Multiplan Commercial |
$684.29
|
| Rate for Payer: Networks By Design Commercial |
$427.68
|
| Rate for Payer: Prime Health Services Commercial |
$727.06
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT. [40814135]
|
Facility
IP
|
$855.36
|
|
|
Service Code
|
CPT J9218
|
| Hospital Charge Code |
1756590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$205.29 |
| Max. Negotiated Rate |
$727.06 |
| Rate for Payer: Blue Shield of California Commercial |
$609.02
|
| Rate for Payer: Blue Shield of California EPN |
$437.94
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cigna of CA HMO |
$598.75
|
| Rate for Payer: Cigna of CA PPO |
$598.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$342.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$342.14
|
| Rate for Payer: Galaxy Health WC |
$727.06
|
| Rate for Payer: Global Benefits Group Commercial |
$513.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$570.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$325.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$205.29
|
| Rate for Payer: Multiplan Commercial |
$684.29
|
| Rate for Payer: Networks By Design Commercial |
$427.68
|
| Rate for Payer: Prime Health Services Commercial |
$727.06
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT. [40814135]
|
Facility
OP
|
$855.36
|
|
|
Service Code
|
CPT J9218
|
| Hospital Charge Code |
1756590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.74 |
| Max. Negotiated Rate |
$727.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$183.60
|
| Rate for Payer: BCBS Transplant Transplant |
$513.22
|
| Rate for Payer: Blue Shield of California Commercial |
$630.40
|
| Rate for Payer: Blue Shield of California EPN |
$60.79
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cigna of CA HMO |
$598.75
|
| Rate for Payer: Cigna of CA PPO |
$598.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.62
|
| Rate for Payer: Dignity Health Media |
$13.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.56
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$13.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.74
|
| Rate for Payer: Galaxy Health WC |
$727.06
|
| Rate for Payer: Global Benefits Group Commercial |
$513.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$641.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.54
|
| Rate for Payer: Heritage Provider Network Transplant |
$22.54
|
| Rate for Payer: IEHP Medi-Cal |
$22.27
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$22.27
|
| Rate for Payer: IEHP Medicare Advantage |
$13.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$570.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$325.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$205.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.42
|
| Rate for Payer: Multiplan Commercial |
$684.29
|
| Rate for Payer: Networks By Design Commercial |
$427.68
|
| Rate for Payer: Prime Health Services Commercial |
$727.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$513.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$513.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$427.68
|
| Rate for Payer: United Healthcare All Other HMO |
$427.68
|
| Rate for Payer: United Healthcare HMO Rider |
$427.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$427.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: Vantage Medical Group Senior |
$13.74
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21045]
|
Facility
OP
|
$7,008.31
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1720692
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$5,957.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$357.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$226.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$199.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,143.48
|
| Rate for Payer: BCBS Transplant Transplant |
$4,204.99
|
| Rate for Payer: Blue Shield of California Commercial |
$5,165.12
|
| Rate for Payer: Blue Shield of California EPN |
$542.03
|
| Rate for Payer: Cash Price |
$3,153.74
|
| Rate for Payer: Cash Price |
$3,153.74
|
| Rate for Payer: Cigna of CA HMO |
$4,905.82
|
| Rate for Payer: Cigna of CA PPO |
$4,905.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$271.95
|
| Rate for Payer: Dignity Health Media |
$181.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$199.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$244.76
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$181.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$181.30
|
| Rate for Payer: Galaxy Health WC |
$5,957.06
|
| Rate for Payer: Global Benefits Group Commercial |
$4,204.99
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5,256.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$297.34
|
| Rate for Payer: Heritage Provider Network Transplant |
$297.34
|
| Rate for Payer: IEHP Medi-Cal |
$293.71
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$293.71
|
| Rate for Payer: IEHP Medicare Advantage |
$181.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,674.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$352.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$181.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,681.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$228.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$242.94
|
| Rate for Payer: Multiplan Commercial |
$5,606.65
|
| Rate for Payer: Networks By Design Commercial |
$3,504.16
|
| Rate for Payer: Prime Health Services Commercial |
$5,957.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4,204.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4,204.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,504.16
|
| Rate for Payer: United Healthcare All Other HMO |
$3,504.16
|
| Rate for Payer: United Healthcare HMO Rider |
$3,504.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,504.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$271.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Vantage Medical Group Senior |
$181.30
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21045]
|
Facility
IP
|
$7,008.31
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1720692
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,681.99 |
| Max. Negotiated Rate |
$5,957.06 |
| Rate for Payer: Blue Shield of California Commercial |
$4,989.92
|
| Rate for Payer: Blue Shield of California EPN |
$3,588.25
|
| Rate for Payer: Cash Price |
$3,153.74
|
| Rate for Payer: Cigna of CA HMO |
$4,905.82
|
| Rate for Payer: Cigna of CA PPO |
$4,905.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,803.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,803.32
|
| Rate for Payer: Galaxy Health WC |
$5,957.06
|
| Rate for Payer: Global Benefits Group Commercial |
$4,204.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,674.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,670.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,681.99
|
| Rate for Payer: Multiplan Commercial |
$5,606.65
|
| Rate for Payer: Networks By Design Commercial |
$3,504.16
|
| Rate for Payer: Prime Health Services Commercial |
$5,957.06
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]
|
Facility
OP
|
$1,626.08
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1721163
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$1,382.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$357.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$226.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$199.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,143.48
|
| Rate for Payer: BCBS Transplant Transplant |
$975.65
|
| Rate for Payer: Blue Shield of California Commercial |
$1,198.42
|
| Rate for Payer: Blue Shield of California EPN |
$542.03
|
| Rate for Payer: Cash Price |
$731.74
|
| Rate for Payer: Cash Price |
$731.74
|
| Rate for Payer: Cigna of CA HMO |
$1,138.26
|
| Rate for Payer: Cigna of CA PPO |
$1,138.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$271.95
|
| Rate for Payer: Dignity Health Media |
$181.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$199.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$244.76
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$181.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$181.30
|
| Rate for Payer: Galaxy Health WC |
$1,382.17
|
| Rate for Payer: Global Benefits Group Commercial |
$975.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,219.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$297.34
|
| Rate for Payer: Heritage Provider Network Transplant |
$297.34
|
| Rate for Payer: IEHP Medi-Cal |
$293.71
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$293.71
|
| Rate for Payer: IEHP Medicare Advantage |
$181.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,084.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$352.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$181.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$390.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$228.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$242.94
|
| Rate for Payer: Multiplan Commercial |
$1,300.86
|
| Rate for Payer: Networks By Design Commercial |
$813.04
|
| Rate for Payer: Prime Health Services Commercial |
$1,382.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$975.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$975.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$813.04
|
| Rate for Payer: United Healthcare All Other HMO |
$813.04
|
| Rate for Payer: United Healthcare HMO Rider |
$813.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$813.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$271.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Vantage Medical Group Senior |
$181.30
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]
|
Facility
IP
|
$1,626.08
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1721163
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$390.26 |
| Max. Negotiated Rate |
$1,382.17 |
| Rate for Payer: Blue Shield of California Commercial |
$1,157.77
|
| Rate for Payer: Blue Shield of California EPN |
$832.55
|
| Rate for Payer: Cash Price |
$731.74
|
| Rate for Payer: Cigna of CA HMO |
$1,138.26
|
| Rate for Payer: Cigna of CA PPO |
$1,138.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$650.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$650.43
|
| Rate for Payer: Galaxy Health WC |
$1,382.17
|
| Rate for Payer: Global Benefits Group Commercial |
$975.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,084.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$619.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$390.26
|
| Rate for Payer: Multiplan Commercial |
$1,300.86
|
| Rate for Payer: Networks By Design Commercial |
$813.04
|
| Rate for Payer: Prime Health Services Commercial |
$1,382.17
|
|
|
LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT [21108]
|
Facility
IP
|
$9,344.44
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1720911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,242.67 |
| Max. Negotiated Rate |
$7,942.77 |
| Rate for Payer: Blue Shield of California Commercial |
$6,653.24
|
| Rate for Payer: Blue Shield of California EPN |
$4,784.35
|
| Rate for Payer: Cash Price |
$4,205.00
|
| Rate for Payer: Cigna of CA HMO |
$6,541.11
|
| Rate for Payer: Cigna of CA PPO |
$6,541.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,737.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,737.78
|
| Rate for Payer: Galaxy Health WC |
$7,942.77
|
| Rate for Payer: Global Benefits Group Commercial |
$5,606.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6,232.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,560.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,242.67
|
| Rate for Payer: Multiplan Commercial |
$7,475.55
|
| Rate for Payer: Networks By Design Commercial |
$4,672.22
|
| Rate for Payer: Prime Health Services Commercial |
$7,942.77
|
|
|
LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT [21108]
|
Facility
OP
|
$9,344.44
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1720911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$7,942.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$357.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$226.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$199.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,143.48
|
| Rate for Payer: BCBS Transplant Transplant |
$5,606.66
|
| Rate for Payer: Blue Shield of California Commercial |
$6,886.85
|
| Rate for Payer: Blue Shield of California EPN |
$542.03
|
| Rate for Payer: Cash Price |
$4,205.00
|
| Rate for Payer: Cash Price |
$4,205.00
|
| Rate for Payer: Cigna of CA HMO |
$6,541.11
|
| Rate for Payer: Cigna of CA PPO |
$6,541.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$271.95
|
| Rate for Payer: Dignity Health Media |
$181.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$199.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$244.76
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$181.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$181.30
|
| Rate for Payer: Galaxy Health WC |
$7,942.77
|
| Rate for Payer: Global Benefits Group Commercial |
$5,606.66
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$7,008.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$297.34
|
| Rate for Payer: Heritage Provider Network Transplant |
$297.34
|
| Rate for Payer: IEHP Medi-Cal |
$293.71
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$293.71
|
| Rate for Payer: IEHP Medicare Advantage |
$181.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6,232.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$352.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$181.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,242.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$228.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$242.94
|
| Rate for Payer: Multiplan Commercial |
$7,475.55
|
| Rate for Payer: Networks By Design Commercial |
$4,672.22
|
| Rate for Payer: Prime Health Services Commercial |
$7,942.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5,606.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5,606.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,672.22
|
| Rate for Payer: United Healthcare All Other HMO |
$4,672.22
|
| Rate for Payer: United Healthcare HMO Rider |
$4,672.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,672.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$271.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$199.43
|
| Rate for Payer: Vantage Medical Group Senior |
$181.30
|
|
|
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [13691]
|
Facility
IP
|
$1,960.39
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
1721031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$470.49 |
| Max. Negotiated Rate |
$1,666.33 |
| Rate for Payer: Blue Shield of California Commercial |
$1,395.80
|
| Rate for Payer: Blue Shield of California EPN |
$1,003.72
|
| Rate for Payer: Cash Price |
$882.18
|
| Rate for Payer: Cigna of CA HMO |
$1,372.27
|
| Rate for Payer: Cigna of CA PPO |
$1,372.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$784.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$784.16
|
| Rate for Payer: Galaxy Health WC |
$1,666.33
|
| Rate for Payer: Global Benefits Group Commercial |
$1,176.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,307.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$746.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$470.49
|
| Rate for Payer: Multiplan Commercial |
$1,568.31
|
| Rate for Payer: Networks By Design Commercial |
$980.20
|
| Rate for Payer: Prime Health Services Commercial |
$1,666.33
|
|
