|
LOXAPINE SUCCINATE 10 MG CAPSULE [4599]
|
Facility
IP
|
$0.86
|
|
|
Service Code
|
NDC 0527-1395-01
|
| Hospital Charge Code |
1712344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.60
|
| Rate for Payer: Cigna of CA PPO |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.73
|
| Rate for Payer: Global Benefits Group Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| Rate for Payer: Networks By Design Commercial |
$0.56
|
| Rate for Payer: Prime Health Services Commercial |
$0.73
|
|
|
LOXAPINE SUCCINATE 10 MG CAPSULE [4599]
|
Facility
OP
|
$0.86
|
|
|
Service Code
|
NDC 0527-1395-01
|
| Hospital Charge Code |
1712344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.51
|
| Rate for Payer: BCBS Transplant Transplant |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.60
|
| Rate for Payer: Cigna of CA PPO |
$0.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Media |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.73
|
| Rate for Payer: Global Benefits Group Commercial |
$0.52
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| Rate for Payer: Networks By Design Commercial |
$0.56
|
| Rate for Payer: Prime Health Services Commercial |
$0.73
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.43
|
| Rate for Payer: United Healthcare All Other HMO |
$0.43
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
LOXAPINE SUCCINATE 10 MG CAPSULE [4599]
|
Facility
OP
|
$0.86
|
|
|
Service Code
|
NDC 0591-0370-01
|
| Hospital Charge Code |
1712344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.51
|
| Rate for Payer: BCBS Transplant Transplant |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.60
|
| Rate for Payer: Cigna of CA PPO |
$0.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Media |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.73
|
| Rate for Payer: Global Benefits Group Commercial |
$0.52
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| Rate for Payer: Networks By Design Commercial |
$0.56
|
| Rate for Payer: Prime Health Services Commercial |
$0.73
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.43
|
| Rate for Payer: United Healthcare All Other HMO |
$0.43
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
LOXAPINE SUCCINATE 10 MG CAPSULE [4599]
|
Facility
IP
|
$0.86
|
|
|
Service Code
|
NDC 0591-0370-01
|
| Hospital Charge Code |
1712344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.60
|
| Rate for Payer: Cigna of CA PPO |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.73
|
| Rate for Payer: Global Benefits Group Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| Rate for Payer: Networks By Design Commercial |
$0.56
|
| Rate for Payer: Prime Health Services Commercial |
$0.73
|
|
|
LUBIPROSTONE 24 MCG CAPSULE [70472]
|
Facility
IP
|
$7.42
|
|
|
Service Code
|
NDC 64764-240-60
|
| Hospital Charge Code |
1711906
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$6.31 |
| Rate for Payer: Blue Shield of California Commercial |
$5.28
|
| Rate for Payer: Blue Shield of California EPN |
$3.80
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cigna of CA HMO |
$5.19
|
| Rate for Payer: Cigna of CA PPO |
$5.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.97
|
| Rate for Payer: Galaxy Health WC |
$6.31
|
| Rate for Payer: Global Benefits Group Commercial |
$4.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.94
|
| Rate for Payer: Networks By Design Commercial |
$4.82
|
| Rate for Payer: Prime Health Services Commercial |
$6.31
|
|
|
LUBIPROSTONE 24 MCG CAPSULE [70472]
|
Facility
IP
|
$5.94
|
|
|
Service Code
|
NDC 0254-3029-02
|
| Hospital Charge Code |
1711906
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Blue Shield of California Commercial |
$4.23
|
| Rate for Payer: Blue Shield of California EPN |
$3.04
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Cigna of CA HMO |
$4.16
|
| Rate for Payer: Cigna of CA PPO |
$4.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: Galaxy Health WC |
$5.05
|
| Rate for Payer: Global Benefits Group Commercial |
$3.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$4.75
|
| Rate for Payer: Networks By Design Commercial |
$3.86
|
| Rate for Payer: Prime Health Services Commercial |
$5.05
|
|
|
LUBIPROSTONE 24 MCG CAPSULE [70472]
|
Facility
OP
|
$7.42
|
|
|
Service Code
|
NDC 64764-240-60
|
| Hospital Charge Code |
1711906
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$6.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.42
|
| Rate for Payer: BCBS Transplant Transplant |
$4.45
|
| Rate for Payer: Blue Shield of California Commercial |
$5.47
|
| Rate for Payer: Blue Shield of California EPN |
$4.33
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cigna of CA HMO |
$5.19
|
| Rate for Payer: Cigna of CA PPO |
$5.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.31
|
| Rate for Payer: Dignity Health Media |
$6.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.97
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.97
|
| Rate for Payer: Galaxy Health WC |
$6.31
|
| Rate for Payer: Global Benefits Group Commercial |
$4.45
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.94
|
| Rate for Payer: Networks By Design Commercial |
$4.82
|
| Rate for Payer: Prime Health Services Commercial |
$6.31
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.45
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.71
|
| Rate for Payer: United Healthcare All Other HMO |
$3.71
|
| Rate for Payer: United Healthcare HMO Rider |
$3.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.31
|
| Rate for Payer: Vantage Medical Group Senior |
$6.31
|
|
|
LUBIPROSTONE 24 MCG CAPSULE [70472]
|
Facility
OP
|
$2.12
|
|
|
Service Code
|
NDC 0480-4138-06
|
| Hospital Charge Code |
1711906
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.26
|
| Rate for Payer: BCBS Transplant Transplant |
$1.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO |
$1.48
|
| Rate for Payer: Cigna of CA PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.80
|
| Rate for Payer: Dignity Health Media |
$1.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.80
|
| Rate for Payer: Global Benefits Group Commercial |
$1.27
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.80
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.06
|
| Rate for Payer: United Healthcare All Other HMO |
$1.06
|
| Rate for Payer: United Healthcare HMO Rider |
$1.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1.80
|
|
|
LUBIPROSTONE 24 MCG CAPSULE [70472]
|
Facility
OP
|
$5.94
|
|
|
Service Code
|
NDC 0254-3029-02
|
| Hospital Charge Code |
1711906
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: BCBS Transplant Transplant |
$3.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.54
|
| Rate for Payer: Blue Shield of California Commercial |
$4.38
|
| Rate for Payer: Blue Shield of California EPN |
$3.47
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Cigna of CA HMO |
$4.16
|
| Rate for Payer: Cigna of CA PPO |
$4.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.05
|
| Rate for Payer: Dignity Health Media |
$5.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.38
|
| Rate for Payer: Galaxy Health WC |
$5.05
|
| Rate for Payer: Global Benefits Group Commercial |
$3.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$4.75
|
| Rate for Payer: Networks By Design Commercial |
$3.86
|
| Rate for Payer: Prime Health Services Commercial |
$5.05
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.97
|
| Rate for Payer: United Healthcare All Other HMO |
$2.97
|
| Rate for Payer: United Healthcare HMO Rider |
$2.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.05
|
| Rate for Payer: Vantage Medical Group Senior |
$5.05
|
|
|
LUBIPROSTONE 24 MCG CAPSULE [70472]
|
Facility
IP
|
$2.12
|
|
|
Service Code
|
NDC 0480-4138-06
|
| Hospital Charge Code |
1711906
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Blue Shield of California Commercial |
$1.51
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO |
$1.48
|
| Rate for Payer: Cigna of CA PPO |
$1.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.80
|
| Rate for Payer: Global Benefits Group Commercial |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.80
|
|
|
LUBIPROSTONE 8 MCG CAPSULE [91534]
|
Facility
IP
|
$7.42
|
|
|
Service Code
|
NDC 64764-080-60
|
| Hospital Charge Code |
1712473
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$6.31 |
| Rate for Payer: Blue Shield of California Commercial |
$5.28
|
| Rate for Payer: Blue Shield of California EPN |
$3.80
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cigna of CA HMO |
$5.19
|
| Rate for Payer: Cigna of CA PPO |
$5.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.97
|
| Rate for Payer: Galaxy Health WC |
$6.31
|
| Rate for Payer: Global Benefits Group Commercial |
$4.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.94
|
| Rate for Payer: Networks By Design Commercial |
$4.82
|
| Rate for Payer: Prime Health Services Commercial |
$6.31
|
|
|
LUBIPROSTONE 8 MCG CAPSULE [91534]
|
Facility
OP
|
$7.42
|
|
|
Service Code
|
NDC 64764-080-60
|
| Hospital Charge Code |
1712473
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$6.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.42
|
| Rate for Payer: BCBS Transplant Transplant |
$4.45
|
| Rate for Payer: Blue Shield of California Commercial |
$5.47
|
| Rate for Payer: Blue Shield of California EPN |
$4.33
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cigna of CA HMO |
$5.19
|
| Rate for Payer: Cigna of CA PPO |
$5.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.31
|
| Rate for Payer: Dignity Health Media |
$6.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.97
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.97
|
| Rate for Payer: Galaxy Health WC |
$6.31
|
| Rate for Payer: Global Benefits Group Commercial |
$4.45
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.94
|
| Rate for Payer: Networks By Design Commercial |
$4.82
|
| Rate for Payer: Prime Health Services Commercial |
$6.31
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.45
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.71
|
| Rate for Payer: United Healthcare All Other HMO |
$3.71
|
| Rate for Payer: United Healthcare HMO Rider |
$3.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.31
|
| Rate for Payer: Vantage Medical Group Senior |
$6.31
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
IP
|
$56.75
|
|
|
Service Code
|
NDC 63402-304-30
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.62 |
| Max. Negotiated Rate |
$48.24 |
| Rate for Payer: Blue Shield of California Commercial |
$40.41
|
| Rate for Payer: Blue Shield of California EPN |
$29.06
|
| Rate for Payer: Cash Price |
$25.54
|
| Rate for Payer: Cigna of CA HMO |
$39.72
|
| Rate for Payer: Cigna of CA PPO |
$39.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.70
|
| Rate for Payer: Galaxy Health WC |
$48.24
|
| Rate for Payer: Global Benefits Group Commercial |
$34.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.62
|
| Rate for Payer: Multiplan Commercial |
$45.40
|
| Rate for Payer: Networks By Design Commercial |
$36.89
|
| Rate for Payer: Prime Health Services Commercial |
$48.24
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
IP
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-11
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$2.63
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO |
$3.59
|
| Rate for Payer: Cigna of CA PPO |
$3.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$4.10
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
IP
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-21
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$2.63
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO |
$3.59
|
| Rate for Payer: Cigna of CA PPO |
$3.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$4.10
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
OP
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-11
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.06
|
| Rate for Payer: BCBS Transplant Transplant |
$3.08
|
| Rate for Payer: Blue Shield of California Commercial |
$3.78
|
| Rate for Payer: Blue Shield of California EPN |
$3.00
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO |
$3.59
|
| Rate for Payer: Cigna of CA PPO |
$3.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.36
|
| Rate for Payer: Dignity Health Media |
$4.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$4.10
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.56
|
| Rate for Payer: United Healthcare All Other HMO |
$2.56
|
| Rate for Payer: United Healthcare HMO Rider |
$2.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.36
|
| Rate for Payer: Vantage Medical Group Senior |
$4.36
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
OP
|
$56.75
|
|
|
Service Code
|
NDC 63402-304-30
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.62 |
| Max. Negotiated Rate |
$48.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$37.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$48.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$31.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$31.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.81
|
| Rate for Payer: BCBS Transplant Transplant |
$34.05
|
| Rate for Payer: Blue Shield of California Commercial |
$41.82
|
| Rate for Payer: Blue Shield of California EPN |
$33.14
|
| Rate for Payer: Cash Price |
$25.54
|
| Rate for Payer: Cigna of CA HMO |
$39.72
|
| Rate for Payer: Cigna of CA PPO |
$39.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.24
|
| Rate for Payer: Dignity Health Media |
$48.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$22.70
|
| Rate for Payer: Galaxy Health WC |
$48.24
|
| Rate for Payer: Global Benefits Group Commercial |
$34.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$42.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.62
|
| Rate for Payer: Multiplan Commercial |
$45.40
|
| Rate for Payer: Networks By Design Commercial |
$36.89
|
| Rate for Payer: Prime Health Services Commercial |
$48.24
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$34.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$34.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$34.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$28.38
|
| Rate for Payer: United Healthcare All Other HMO |
$28.38
|
| Rate for Payer: United Healthcare HMO Rider |
$28.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$48.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.24
|
| Rate for Payer: Vantage Medical Group Senior |
$48.24
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
OP
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-21
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.06
|
| Rate for Payer: BCBS Transplant Transplant |
$3.08
|
| Rate for Payer: Blue Shield of California Commercial |
$3.78
|
| Rate for Payer: Blue Shield of California EPN |
$3.00
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO |
$3.59
|
| Rate for Payer: Cigna of CA PPO |
$3.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.36
|
| Rate for Payer: Dignity Health Media |
$4.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$4.10
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.56
|
| Rate for Payer: United Healthcare All Other HMO |
$2.56
|
| Rate for Payer: United Healthcare HMO Rider |
$2.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.36
|
| Rate for Payer: Vantage Medical Group Senior |
$4.36
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
OP
|
$2.13
|
|
|
Service Code
|
NDC 47335-684-83
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.27
|
| Rate for Payer: BCBS Transplant Transplant |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.81
|
| Rate for Payer: Dignity Health Media |
$1.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.85
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.06
|
| Rate for Payer: United Healthcare All Other HMO |
$1.06
|
| Rate for Payer: United Healthcare HMO Rider |
$1.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
IP
|
$2.13
|
|
|
Service Code
|
NDC 47335-684-83
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
|
|
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [228261]
|
Facility
OP
|
$9,396.00
|
|
|
Service Code
|
NDC 68727-712-01
|
| Hospital Charge Code |
ERX408205864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,255.04 |
| Max. Negotiated Rate |
$7,986.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6,162.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,986.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5,167.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5,167.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,598.14
|
| Rate for Payer: BCBS Transplant Transplant |
$5,637.60
|
| Rate for Payer: Blue Shield of California Commercial |
$6,924.85
|
| Rate for Payer: Blue Shield of California EPN |
$5,487.26
|
| Rate for Payer: Cash Price |
$4,228.20
|
| Rate for Payer: Cash Price |
$4,228.20
|
| Rate for Payer: Cigna of CA HMO |
$6,577.20
|
| Rate for Payer: Cigna of CA PPO |
$6,577.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,986.60
|
| Rate for Payer: Dignity Health Media |
$7,986.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,986.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,758.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,758.40
|
| Rate for Payer: Galaxy Health WC |
$7,986.60
|
| Rate for Payer: Global Benefits Group Commercial |
$5,637.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$7,047.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6,267.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,579.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,255.04
|
| Rate for Payer: Multiplan Commercial |
$7,516.80
|
| Rate for Payer: Networks By Design Commercial |
$4,698.00
|
| Rate for Payer: Prime Health Services Commercial |
$7,986.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5,637.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5,637.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,698.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4,698.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,698.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,698.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,986.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,986.60
|
| Rate for Payer: Vantage Medical Group Senior |
$7,986.60
|
|
|
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [228261]
|
Facility
IP
|
$9,396.00
|
|
|
Service Code
|
NDC 68727-712-01
|
| Hospital Charge Code |
ERX408205864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,255.04 |
| Max. Negotiated Rate |
$7,986.60 |
| Rate for Payer: Cash Price |
$4,228.20
|
| Rate for Payer: Blue Shield of California Commercial |
$6,689.95
|
| Rate for Payer: Blue Shield of California EPN |
$4,810.75
|
| Rate for Payer: Cigna of CA HMO |
$6,577.20
|
| Rate for Payer: Cigna of CA PPO |
$6,577.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,758.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,758.40
|
| Rate for Payer: Galaxy Health WC |
$7,986.60
|
| Rate for Payer: Global Benefits Group Commercial |
$5,637.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6,267.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,579.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,255.04
|
| Rate for Payer: Multiplan Commercial |
$7,516.80
|
| Rate for Payer: Networks By Design Commercial |
$4,698.00
|
| Rate for Payer: Prime Health Services Commercial |
$7,986.60
|
|
|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [225877]
|
Facility
OP
|
$4,559.88
|
|
|
Service Code
|
CPT J0896
|
| Hospital Charge Code |
ERX225877
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.97 |
| Max. Negotiated Rate |
$3,875.90 |
| Rate for Payer: Aetna of CA HMO/PPO |
$251.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$49.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$43.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$43.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.44
|
| Rate for Payer: BCBS Transplant Transplant |
$2,735.93
|
| Rate for Payer: Blue Shield of California Commercial |
$3,360.63
|
| Rate for Payer: Blue Shield of California EPN |
$41.29
|
| Rate for Payer: Cash Price |
$2,051.95
|
| Rate for Payer: Cash Price |
$2,051.95
|
| Rate for Payer: Cigna of CA HMO |
$3,191.92
|
| Rate for Payer: Cigna of CA PPO |
$3,191.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.96
|
| Rate for Payer: Dignity Health Media |
$43.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$39.97
|
| Rate for Payer: EPIC Health Plan Transplant |
$39.97
|
| Rate for Payer: Galaxy Health WC |
$3,875.90
|
| Rate for Payer: Global Benefits Group Commercial |
$2,735.93
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3,419.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.55
|
| Rate for Payer: Heritage Provider Network Transplant |
$65.55
|
| Rate for Payer: IEHP Medi-Cal |
$64.75
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$64.75
|
| Rate for Payer: IEHP Medicare Advantage |
$39.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,041.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$39.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,094.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$50.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$53.56
|
| Rate for Payer: Multiplan Commercial |
$3,647.90
|
| Rate for Payer: Networks By Design Commercial |
$2,279.94
|
| Rate for Payer: Prime Health Services Commercial |
$3,875.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,735.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,735.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,279.94
|
| Rate for Payer: United Healthcare All Other HMO |
$2,279.94
|
| Rate for Payer: United Healthcare HMO Rider |
$2,279.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,279.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$49.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.97
|
| Rate for Payer: Vantage Medical Group Senior |
$43.97
|
|
|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [225877]
|
Facility
IP
|
$4,559.88
|
|
|
Service Code
|
CPT J0896
|
| Hospital Charge Code |
ERX225877
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,094.37 |
| Max. Negotiated Rate |
$3,875.90 |
| Rate for Payer: Blue Shield of California Commercial |
$3,246.63
|
| Rate for Payer: Blue Shield of California EPN |
$2,334.66
|
| Rate for Payer: Cash Price |
$2,051.95
|
| Rate for Payer: Cigna of CA HMO |
$3,191.92
|
| Rate for Payer: Cigna of CA PPO |
$3,191.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,823.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,823.95
|
| Rate for Payer: Galaxy Health WC |
$3,875.90
|
| Rate for Payer: Global Benefits Group Commercial |
$2,735.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,041.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,737.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,094.37
|
| Rate for Payer: Multiplan Commercial |
$3,647.90
|
| Rate for Payer: Networks By Design Commercial |
$2,279.94
|
| Rate for Payer: Prime Health Services Commercial |
$3,875.90
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [225879]
|
Facility
IP
|
$13,679.62
|
|
|
Service Code
|
CPT J0896
|
| Hospital Charge Code |
ERX225879
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,283.11 |
| Max. Negotiated Rate |
$11,627.68 |
| Rate for Payer: Blue Shield of California Commercial |
$9,739.89
|
| Rate for Payer: Blue Shield of California EPN |
$7,003.97
|
| Rate for Payer: Cash Price |
$6,155.83
|
| Rate for Payer: Cigna of CA HMO |
$9,575.73
|
| Rate for Payer: Cigna of CA PPO |
$9,575.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,471.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$5,471.85
|
| Rate for Payer: Galaxy Health WC |
$11,627.68
|
| Rate for Payer: Global Benefits Group Commercial |
$8,207.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9,124.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,211.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,283.11
|
| Rate for Payer: Multiplan Commercial |
$10,943.70
|
| Rate for Payer: Networks By Design Commercial |
$6,839.81
|
| Rate for Payer: Prime Health Services Commercial |
$11,627.68
|
|
