|
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [13691]
|
Facility
OP
|
$1,960.39
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
1721031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$470.49 |
| Max. Negotiated Rate |
$9,840.53 |
| Rate for Payer: IEHP Medicare Advantage |
$1,564.60
|
| 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 |
$1,176.23
|
| Rate for Payer: Blue Shield of California Commercial |
$1,444.81
|
| Rate for Payer: Blue Shield of California EPN |
$1,675.92
|
| Rate for Payer: Cash Price |
$882.18
|
| 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: 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 |
$1,666.33
|
| Rate for Payer: Global Benefits Group Commercial |
$1,176.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,470.29
|
| 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: Kaiser Permanente of CA Commercial/Self Funded |
$1,307.58
|
| 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 |
$470.49
|
| 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 |
$1,568.31
|
| Rate for Payer: Networks By Design Commercial |
$980.20
|
| Rate for Payer: Prime Health Services Commercial |
$1,666.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,176.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,176.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$980.20
|
| Rate for Payer: United Healthcare All Other HMO |
$980.20
|
| Rate for Payer: United Healthcare HMO Rider |
$980.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$980.20
|
| 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 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]
|
Facility
IP
|
$542.03
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1721162
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.09 |
| Max. Negotiated Rate |
$460.73 |
| Rate for Payer: Blue Shield of California Commercial |
$385.93
|
| Rate for Payer: Blue Shield of California EPN |
$277.52
|
| Rate for Payer: Cash Price |
$243.91
|
| Rate for Payer: Cigna of CA HMO |
$379.42
|
| Rate for Payer: Cigna of CA PPO |
$379.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$216.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$216.81
|
| Rate for Payer: Galaxy Health WC |
$460.73
|
| Rate for Payer: Global Benefits Group Commercial |
$325.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$361.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$206.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$130.09
|
| Rate for Payer: Multiplan Commercial |
$433.62
|
| Rate for Payer: Networks By Design Commercial |
$271.02
|
| Rate for Payer: Prime Health Services Commercial |
$460.73
|
|
|
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]
|
Facility
OP
|
$542.03
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1721162
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.09 |
| Max. Negotiated Rate |
$1,143.48 |
| 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 |
$325.22
|
| Rate for Payer: Blue Shield of California Commercial |
$399.48
|
| Rate for Payer: Blue Shield of California EPN |
$542.03
|
| Rate for Payer: Cash Price |
$243.91
|
| Rate for Payer: Cash Price |
$243.91
|
| Rate for Payer: Cigna of CA HMO |
$379.42
|
| Rate for Payer: Cigna of CA PPO |
$379.42
|
| 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 |
$460.73
|
| Rate for Payer: Global Benefits Group Commercial |
$325.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$406.52
|
| 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 |
$361.53
|
| 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 |
$130.09
|
| 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 |
$433.62
|
| Rate for Payer: Networks By Design Commercial |
$271.02
|
| Rate for Payer: Prime Health Services Commercial |
$460.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$325.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$325.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$271.02
|
| Rate for Payer: United Healthcare All Other HMO |
$271.02
|
| Rate for Payer: United Healthcare HMO Rider |
$271.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$271.02
|
| 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 7.5 MG INTRAMUSCULAR SYRINGE KIT [187503]
|
Facility
OP
|
$2,336.11
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
ERX187503
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$1,985.69 |
| 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 |
$1,401.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1,721.71
|
| Rate for Payer: Blue Shield of California EPN |
$542.03
|
| Rate for Payer: Cash Price |
$1,051.25
|
| Rate for Payer: Cash Price |
$1,051.25
|
| Rate for Payer: Cigna of CA HMO |
$1,635.28
|
| Rate for Payer: Cigna of CA PPO |
$1,635.28
|
| 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 |
$1,985.69
|
| Rate for Payer: Global Benefits Group Commercial |
$1,401.67
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,752.08
|
| 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 |
$1,558.19
|
| 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 |
$560.67
|
| 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 |
$1,868.89
|
| Rate for Payer: Networks By Design Commercial |
$1,168.06
|
| Rate for Payer: Prime Health Services Commercial |
$1,985.69
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,401.67
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,401.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,168.06
|
| Rate for Payer: United Healthcare All Other HMO |
$1,168.06
|
| Rate for Payer: United Healthcare HMO Rider |
$1,168.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,168.06
|
| 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 7.5 MG INTRAMUSCULAR SYRINGE KIT [187503]
|
Facility
IP
|
$2,336.11
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
ERX187503
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$560.67 |
| Max. Negotiated Rate |
$1,985.69 |
| Rate for Payer: Blue Shield of California Commercial |
$1,663.31
|
| Rate for Payer: Blue Shield of California EPN |
$1,196.09
|
| Rate for Payer: Cash Price |
$1,051.25
|
| Rate for Payer: Cigna of CA HMO |
$1,635.28
|
| Rate for Payer: Cigna of CA PPO |
$1,635.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$934.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$934.44
|
| Rate for Payer: Galaxy Health WC |
$1,985.69
|
| Rate for Payer: Global Benefits Group Commercial |
$1,401.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,558.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$890.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$560.67
|
| Rate for Payer: Multiplan Commercial |
$1,868.89
|
| Rate for Payer: Networks By Design Commercial |
$1,168.06
|
| Rate for Payer: Prime Health Services Commercial |
$1,985.69
|
|
|
LEUPROLIDE 7.5 MG (PED) INTRAMUSCULAR KIT [27123]
|
Facility
IP
|
$2,358.36
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1720544
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$566.01 |
| Max. Negotiated Rate |
$2,004.61 |
| Rate for Payer: Blue Shield of California Commercial |
$1,679.15
|
| Rate for Payer: Blue Shield of California EPN |
$1,207.48
|
| Rate for Payer: Cash Price |
$1,061.26
|
| Rate for Payer: Cigna of CA HMO |
$1,650.85
|
| Rate for Payer: Cigna of CA PPO |
$1,650.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$943.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$943.34
|
| Rate for Payer: Galaxy Health WC |
$2,004.61
|
| Rate for Payer: Global Benefits Group Commercial |
$1,415.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,573.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$898.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$566.01
|
| Rate for Payer: Multiplan Commercial |
$1,886.69
|
| Rate for Payer: Networks By Design Commercial |
$1,179.18
|
| Rate for Payer: Prime Health Services Commercial |
$2,004.61
|
|
|
LEUPROLIDE 7.5 MG (PED) INTRAMUSCULAR KIT [27123]
|
Facility
OP
|
$2,358.36
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
1720544
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$2,004.61 |
| Rate for Payer: Cash Price |
$1,061.26
|
| Rate for Payer: Cash Price |
$1,061.26
|
| Rate for Payer: Cigna of CA HMO |
$1,650.85
|
| Rate for Payer: Cigna of CA PPO |
$1,650.85
|
| 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 |
$1,415.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1,738.11
|
| Rate for Payer: Blue Shield of California EPN |
$542.03
|
| 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 |
$2,004.61
|
| Rate for Payer: Global Benefits Group Commercial |
$1,415.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,768.77
|
| 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 |
$1,573.03
|
| 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 |
$566.01
|
| 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 |
$1,886.69
|
| Rate for Payer: Networks By Design Commercial |
$1,179.18
|
| Rate for Payer: Prime Health Services Commercial |
$2,004.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,415.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,415.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,179.18
|
| Rate for Payer: United Healthcare All Other HMO |
$1,179.18
|
| Rate for Payer: United Healthcare HMO Rider |
$1,179.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,179.18
|
| 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 ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [153492]
|
Facility
OP
|
$14,016.85
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
ERX153492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$11,914.32 |
| 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 |
$8,410.11
|
| Rate for Payer: Blue Shield of California Commercial |
$10,330.42
|
| Rate for Payer: Blue Shield of California EPN |
$542.03
|
| Rate for Payer: Cash Price |
$6,307.58
|
| Rate for Payer: Cash Price |
$6,307.58
|
| Rate for Payer: Cigna of CA HMO |
$9,811.80
|
| Rate for Payer: Cigna of CA PPO |
$9,811.80
|
| 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 |
$11,914.32
|
| Rate for Payer: Global Benefits Group Commercial |
$8,410.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$10,512.64
|
| 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 |
$9,349.24
|
| 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 |
$3,364.04
|
| 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 |
$11,213.48
|
| Rate for Payer: Networks By Design Commercial |
$7,008.42
|
| Rate for Payer: Prime Health Services Commercial |
$11,914.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8,410.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8,410.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$7,008.42
|
| Rate for Payer: United Healthcare All Other HMO |
$7,008.42
|
| Rate for Payer: United Healthcare HMO Rider |
$7,008.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,008.42
|
| 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 ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [153492]
|
Facility
IP
|
$14,016.85
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
ERX153492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,364.04 |
| Max. Negotiated Rate |
$11,914.32 |
| Rate for Payer: Blue Shield of California Commercial |
$9,980.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,176.63
|
| Rate for Payer: Cash Price |
$6,307.58
|
| Rate for Payer: Cigna of CA HMO |
$9,811.80
|
| Rate for Payer: Cigna of CA PPO |
$9,811.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,606.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$5,606.74
|
| Rate for Payer: Galaxy Health WC |
$11,914.32
|
| Rate for Payer: Global Benefits Group Commercial |
$8,410.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9,349.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,340.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,364.04
|
| Rate for Payer: Multiplan Commercial |
$11,213.48
|
| Rate for Payer: Networks By Design Commercial |
$7,008.42
|
| Rate for Payer: Prime Health Services Commercial |
$11,914.32
|
|
|
LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]
|
Facility
IP
|
$0.64
|
|
|
Service Code
|
NDC 0093-4148-45
|
| Hospital Charge Code |
1781108
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
|
|
LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]
|
Facility
OP
|
$0.64
|
|
|
Service Code
|
NDC 0093-4148-45
|
| Hospital Charge Code |
1781108
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.38
|
| Rate for Payer: BCBS Transplant Transplant |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Media |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.32
|
| Rate for Payer: United Healthcare HMO Rider |
$0.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154435]
|
Facility
IP
|
$0.13
|
|
|
Service Code
|
CPT J1953
|
| Hospital Charge Code |
NDG154435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
|
|
LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154435]
|
Facility
OP
|
$0.13
|
|
|
Service Code
|
CPT J1953
|
| Hospital Charge Code |
NDG154435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$8.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: BCBS Transplant Transplant |
$0.16
|
| Rate for Payer: BCBS Transplant Transplant |
$0.08
|
| Rate for Payer: BCBS Transplant Transplant |
$0.40
|
| Rate for Payer: BCBS Transplant Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Media |
$0.11
|
| Rate for Payer: Dignity Health Media |
$0.22
|
| Rate for Payer: Dignity Health Media |
$0.31
|
| Rate for Payer: Dignity Health Media |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.27
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
OP
|
$0.11
|
|
|
Service Code
|
NDC 31722-574-47
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: BCBS Transplant Transplant |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
OP
|
$0.15
|
|
|
Service Code
|
NDC 50383-241-16
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: BCBS Transplant Transplant |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Media |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 71093-144-13
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 60432-831-16
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: BCBS Transplant Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Media |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 60432-831-16
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
IP
|
$0.15
|
|
|
Service Code
|
NDC 50383-241-16
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 71093-144-13
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: BCBS Transplant Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Media |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
IP
|
$0.11
|
|
|
Service Code
|
NDC 31722-574-47
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
IP
|
$0.30
|
|
|
Service Code
|
NDC 68084-859-01
|
| Hospital Charge Code |
1712236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
IP
|
$0.30
|
|
|
Service Code
|
NDC 68084-859-11
|
| Hospital Charge Code |
1712236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
OP
|
$0.30
|
|
|
Service Code
|
NDC 68084-859-01
|
| Hospital Charge Code |
1712236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: BCBS Transplant Transplant |
$0.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
OP
|
$0.30
|
|
|
Service Code
|
NDC 68084-859-11
|
| Hospital Charge Code |
1712236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| Rate for Payer: BCBS Transplant Transplant |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
