|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [225879]
|
Facility
OP
|
$13,679.62
|
|
|
Service Code
|
CPT J0896
|
| Hospital Charge Code |
ERX225879
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.97 |
| Max. Negotiated Rate |
$11,627.68 |
| Rate for Payer: Aetna of CA HMO/PPO |
$251.39
|
| Rate for Payer: 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 |
$8,207.77
|
| Rate for Payer: Blue Shield of California Commercial |
$10,081.88
|
| Rate for Payer: Blue Shield of California EPN |
$41.29
|
| Rate for Payer: Cash Price |
$6,155.83
|
| Rate for Payer: Cash Price |
$6,155.83
|
| Rate for Payer: Cigna of CA HMO |
$9,575.73
|
| Rate for Payer: Cigna of CA PPO |
$9,575.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.96
|
| Rate for Payer: Dignity Health Media |
$43.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$39.97
|
| Rate for Payer: EPIC Health Plan Transplant |
$39.97
|
| Rate for Payer: Galaxy Health WC |
$11,627.68
|
| Rate for Payer: Global Benefits Group Commercial |
$8,207.77
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$10,259.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.55
|
| Rate for Payer: Heritage Provider Network Transplant |
$65.55
|
| Rate for Payer: 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 |
$9,124.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$39.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,283.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$50.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$53.56
|
| Rate for Payer: Multiplan Commercial |
$10,943.70
|
| Rate for Payer: Networks By Design Commercial |
$6,839.81
|
| Rate for Payer: Prime Health Services Commercial |
$11,627.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8,207.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8,207.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$6,839.81
|
| Rate for Payer: United Healthcare All Other HMO |
$6,839.81
|
| Rate for Payer: United Healthcare HMO Rider |
$6,839.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,839.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$49.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.97
|
| Rate for Payer: Vantage Medical Group Senior |
$43.97
|
|
|
LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [220890]
|
Facility
IP
|
$58,680.00
|
|
|
Service Code
|
CPT A9513
|
| Hospital Charge Code |
ERX220890
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$14,083.20 |
| Max. Negotiated Rate |
$49,878.00 |
| Rate for Payer: Blue Shield of California Commercial |
$41,780.16
|
| Rate for Payer: Blue Shield of California EPN |
$30,044.16
|
| Rate for Payer: Cash Price |
$26,406.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$23,472.00
|
| Rate for Payer: Galaxy Health WC |
$49,878.00
|
| Rate for Payer: Global Benefits Group Commercial |
$35,208.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39,139.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22,357.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14,083.20
|
| Rate for Payer: Multiplan Commercial |
$46,944.00
|
| Rate for Payer: Networks By Design Commercial |
$38,142.00
|
| Rate for Payer: Prime Health Services Commercial |
$49,878.00
|
|
|
LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [220890]
|
Facility
OP
|
$58,680.00
|
|
|
Service Code
|
CPT A9513
|
| Hospital Charge Code |
ERX220890
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$380.87 |
| Max. Negotiated Rate |
$49,878.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$542.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$571.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$418.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$380.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$506.23
|
| Rate for Payer: BCBS Transplant Transplant |
$35,208.00
|
| Rate for Payer: Blue Shield of California Commercial |
$34,679.88
|
| Rate for Payer: Blue Shield of California EPN |
$27,520.92
|
| Rate for Payer: Cash Price |
$26,406.00
|
| Rate for Payer: Cash Price |
$26,406.00
|
| Rate for Payer: Cigna of CA HMO |
$37,555.20
|
| Rate for Payer: Cigna of CA PPO |
$43,423.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$571.30
|
| Rate for Payer: Dignity Health Media |
$380.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$418.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$514.17
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$380.87
|
| Rate for Payer: EPIC Health Plan Transplant |
$380.87
|
| Rate for Payer: Galaxy Health WC |
$49,878.00
|
| Rate for Payer: Global Benefits Group Commercial |
$35,208.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$44,010.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$624.63
|
| Rate for Payer: Heritage Provider Network Transplant |
$624.63
|
| Rate for Payer: IEHP Medi-Cal |
$617.01
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$617.01
|
| Rate for Payer: IEHP Medicare Advantage |
$380.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39,139.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$529.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$380.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14,083.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$479.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$510.37
|
| Rate for Payer: Multiplan Commercial |
$46,944.00
|
| Rate for Payer: Networks By Design Commercial |
$38,142.00
|
| Rate for Payer: Prime Health Services Commercial |
$49,878.00
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$35,208.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35,208.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35,208.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$29,340.00
|
| Rate for Payer: United Healthcare All Other HMO |
$29,340.00
|
| Rate for Payer: United Healthcare HMO Rider |
$29,340.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29,340.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$571.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$418.96
|
| Rate for Payer: Vantage Medical Group Senior |
$380.87
|
|
|
LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [233901]
|
Facility
IP
|
$52,020.00
|
|
|
Service Code
|
CPT A9607
|
| Hospital Charge Code |
NDG233901
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$12,484.80 |
| Max. Negotiated Rate |
$44,217.00 |
| Rate for Payer: Blue Shield of California Commercial |
$37,038.24
|
| Rate for Payer: Blue Shield of California EPN |
$26,634.24
|
| Rate for Payer: Cash Price |
$23,409.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$20,808.00
|
| Rate for Payer: Galaxy Health WC |
$44,217.00
|
| Rate for Payer: Global Benefits Group Commercial |
$31,212.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34,697.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19,819.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12,484.80
|
| Rate for Payer: Multiplan Commercial |
$41,616.00
|
| Rate for Payer: Networks By Design Commercial |
$33,813.00
|
| Rate for Payer: Prime Health Services Commercial |
$44,217.00
|
|
|
LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [233901]
|
Facility
OP
|
$52,020.00
|
|
|
Service Code
|
CPT A9607
|
| Hospital Charge Code |
NDG233901
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$229.76 |
| Max. Negotiated Rate |
$44,217.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,575.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$344.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$252.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$229.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$452.94
|
| Rate for Payer: BCBS Transplant Transplant |
$31,212.00
|
| Rate for Payer: Blue Shield of California Commercial |
$30,743.82
|
| Rate for Payer: Blue Shield of California EPN |
$24,397.38
|
| Rate for Payer: Cash Price |
$23,409.00
|
| Rate for Payer: Cash Price |
$23,409.00
|
| Rate for Payer: Cigna of CA HMO |
$33,292.80
|
| Rate for Payer: Cigna of CA PPO |
$38,494.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$287.19
|
| Rate for Payer: Dignity Health Media |
$252.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$252.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$310.17
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$229.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$229.76
|
| Rate for Payer: Galaxy Health WC |
$44,217.00
|
| Rate for Payer: Global Benefits Group Commercial |
$31,212.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$39,015.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$376.80
|
| Rate for Payer: Heritage Provider Network Transplant |
$376.80
|
| Rate for Payer: IEHP Medi-Cal |
$372.20
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$372.20
|
| Rate for Payer: IEHP Medicare Advantage |
$229.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34,697.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$411.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$229.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12,484.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$289.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$307.87
|
| Rate for Payer: Multiplan Commercial |
$41,616.00
|
| Rate for Payer: Networks By Design Commercial |
$33,813.00
|
| Rate for Payer: Prime Health Services Commercial |
$44,217.00
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$31,212.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$31,212.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$31,212.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$26,010.00
|
| Rate for Payer: United Healthcare All Other HMO |
$26,010.00
|
| Rate for Payer: United Healthcare HMO Rider |
$26,010.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$26,010.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$287.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$252.73
|
| Rate for Payer: Vantage Medical Group Senior |
$252.73
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
IP
|
$12,020.52
|
|
|
Service Code
|
APR-DRG 6942
|
| Min. Negotiated Rate |
$9,221.00 |
| Max. Negotiated Rate |
$12,020.52 |
| Rate for Payer: IEHP Medi-Cal |
$9,221.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,020.52
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
IP
|
$9,605.05
|
|
|
Service Code
|
APR-DRG 6941
|
| Min. Negotiated Rate |
$7,368.09 |
| Max. Negotiated Rate |
$9,605.05 |
| Rate for Payer: IEHP Medi-Cal |
$7,368.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,605.05
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
IP
|
$17,665.44
|
|
|
Service Code
|
APR-DRG 6943
|
| Min. Negotiated Rate |
$13,551.25 |
| Max. Negotiated Rate |
$17,665.44 |
| Rate for Payer: IEHP Medi-Cal |
$13,551.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,665.44
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
IP
|
$30,514.15
|
|
|
Service Code
|
APR-DRG 6944
|
| Min. Negotiated Rate |
$23,407.57 |
| Max. Negotiated Rate |
$30,514.15 |
| Rate for Payer: IEHP Medi-Cal |
$23,407.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30,514.15
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
IP
|
$13,613.08
|
|
|
Service Code
|
APR-DRG 6911
|
| Min. Negotiated Rate |
$10,442.67 |
| Max. Negotiated Rate |
$13,613.08 |
| Rate for Payer: IEHP Medi-Cal |
$10,442.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,613.08
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
IP
|
$26,431.64
|
|
|
Service Code
|
APR-DRG 6913
|
| Min. Negotiated Rate |
$20,275.85 |
| Max. Negotiated Rate |
$26,431.64 |
| Rate for Payer: IEHP Medi-Cal |
$20,275.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26,431.64
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
IP
|
$49,174.51
|
|
|
Service Code
|
APR-DRG 6914
|
| Min. Negotiated Rate |
$37,722.02 |
| Max. Negotiated Rate |
$49,174.51 |
| Rate for Payer: IEHP Medi-Cal |
$37,722.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49,174.51
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
IP
|
$17,644.16
|
|
|
Service Code
|
APR-DRG 6912
|
| Min. Negotiated Rate |
$13,534.93 |
| Max. Negotiated Rate |
$17,644.16 |
| Rate for Payer: IEHP Medi-Cal |
$13,534.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,644.16
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
OP
|
$447.39
|
|
|
Service Code
|
NDC 66215-501-15
|
| Hospital Charge Code |
ERX203952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$107.37 |
| Max. Negotiated Rate |
$380.28 |
| Rate for Payer: Aetna of CA HMO/PPO |
$293.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$380.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$246.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$246.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$266.55
|
| Rate for Payer: BCBS Transplant Transplant |
$268.43
|
| Rate for Payer: Blue Shield of California Commercial |
$329.73
|
| Rate for Payer: Blue Shield of California EPN |
$261.28
|
| Rate for Payer: Cash Price |
$201.33
|
| Rate for Payer: Cigna of CA HMO |
$313.17
|
| Rate for Payer: Cigna of CA PPO |
$313.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$380.28
|
| Rate for Payer: Dignity Health Media |
$380.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$380.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$178.96
|
| Rate for Payer: Galaxy Health WC |
$380.28
|
| Rate for Payer: Global Benefits Group Commercial |
$268.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$335.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$298.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$170.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.37
|
| Rate for Payer: Multiplan Commercial |
$357.91
|
| Rate for Payer: Networks By Design Commercial |
$290.80
|
| Rate for Payer: Prime Health Services Commercial |
$380.28
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$268.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$268.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$268.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$223.70
|
| Rate for Payer: United Healthcare All Other HMO |
$223.70
|
| Rate for Payer: United Healthcare HMO Rider |
$223.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$223.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$380.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$380.28
|
| Rate for Payer: Vantage Medical Group Senior |
$380.28
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
OP
|
$447.39
|
|
|
Service Code
|
NDC 66215-501-30
|
| Hospital Charge Code |
ERX203952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$107.37 |
| Max. Negotiated Rate |
$380.28 |
| Rate for Payer: Aetna of CA HMO/PPO |
$293.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$380.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$246.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$246.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$266.55
|
| Rate for Payer: BCBS Transplant Transplant |
$268.43
|
| Rate for Payer: Blue Shield of California Commercial |
$329.73
|
| Rate for Payer: Blue Shield of California EPN |
$261.28
|
| Rate for Payer: Cash Price |
$201.33
|
| Rate for Payer: Cigna of CA HMO |
$313.17
|
| Rate for Payer: Cigna of CA PPO |
$313.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$380.28
|
| Rate for Payer: Dignity Health Media |
$380.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$380.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$178.96
|
| Rate for Payer: Galaxy Health WC |
$380.28
|
| Rate for Payer: Global Benefits Group Commercial |
$268.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$335.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$298.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$170.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.37
|
| Rate for Payer: Multiplan Commercial |
$357.91
|
| Rate for Payer: Networks By Design Commercial |
$290.80
|
| Rate for Payer: Prime Health Services Commercial |
$380.28
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$268.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$268.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$268.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$223.70
|
| Rate for Payer: United Healthcare All Other HMO |
$223.70
|
| Rate for Payer: United Healthcare HMO Rider |
$223.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$223.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$380.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$380.28
|
| Rate for Payer: Vantage Medical Group Senior |
$380.28
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
IP
|
$447.39
|
|
|
Service Code
|
NDC 66215-501-15
|
| Hospital Charge Code |
ERX203952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$107.37 |
| Max. Negotiated Rate |
$380.28 |
| Rate for Payer: Blue Shield of California Commercial |
$318.54
|
| Rate for Payer: Blue Shield of California EPN |
$229.06
|
| Rate for Payer: Cash Price |
$201.33
|
| Rate for Payer: Cigna of CA HMO |
$313.17
|
| Rate for Payer: Cigna of CA PPO |
$313.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.96
|
| Rate for Payer: Galaxy Health WC |
$380.28
|
| Rate for Payer: Global Benefits Group Commercial |
$268.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$298.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$170.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.37
|
| Rate for Payer: Multiplan Commercial |
$357.91
|
| Rate for Payer: Networks By Design Commercial |
$290.80
|
| Rate for Payer: Prime Health Services Commercial |
$380.28
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
IP
|
$447.39
|
|
|
Service Code
|
NDC 66215-501-30
|
| Hospital Charge Code |
ERX203952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$107.37 |
| Max. Negotiated Rate |
$380.28 |
| Rate for Payer: Blue Shield of California Commercial |
$318.54
|
| Rate for Payer: Blue Shield of California EPN |
$229.06
|
| Rate for Payer: Cash Price |
$201.33
|
| Rate for Payer: Cigna of CA HMO |
$313.17
|
| Rate for Payer: Cigna of CA PPO |
$313.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.96
|
| Rate for Payer: Galaxy Health WC |
$380.28
|
| Rate for Payer: Global Benefits Group Commercial |
$268.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$298.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$170.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.37
|
| Rate for Payer: Multiplan Commercial |
$357.91
|
| Rate for Payer: Networks By Design Commercial |
$290.80
|
| Rate for Payer: Prime Health Services Commercial |
$380.28
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET [23233]
|
Facility
IP
|
$167.95
|
|
|
Service Code
|
NDC 49884-902-52
|
| Hospital Charge Code |
1743697
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$40.31 |
| Max. Negotiated Rate |
$142.76 |
| Rate for Payer: Blue Shield of California Commercial |
$119.58
|
| Rate for Payer: Blue Shield of California EPN |
$85.99
|
| Rate for Payer: Cash Price |
$75.58
|
| Rate for Payer: Cigna of CA HMO |
$117.56
|
| Rate for Payer: Cigna of CA PPO |
$117.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.18
|
| Rate for Payer: Galaxy Health WC |
$142.76
|
| Rate for Payer: Global Benefits Group Commercial |
$100.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$112.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.31
|
| Rate for Payer: Multiplan Commercial |
$134.36
|
| Rate for Payer: Networks By Design Commercial |
$109.17
|
| Rate for Payer: Prime Health Services Commercial |
$142.76
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET [23233]
|
Facility
OP
|
$167.95
|
|
|
Service Code
|
NDC 49884-902-52
|
| Hospital Charge Code |
1743697
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$40.31 |
| Max. Negotiated Rate |
$142.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$110.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$142.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$92.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$92.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$100.06
|
| Rate for Payer: BCBS Transplant Transplant |
$100.77
|
| Rate for Payer: Blue Shield of California Commercial |
$123.78
|
| Rate for Payer: Blue Shield of California EPN |
$98.08
|
| Rate for Payer: Cash Price |
$75.58
|
| Rate for Payer: Cigna of CA HMO |
$117.56
|
| Rate for Payer: Cigna of CA PPO |
$117.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$142.76
|
| Rate for Payer: Dignity Health Media |
$142.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$142.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$67.18
|
| Rate for Payer: Galaxy Health WC |
$142.76
|
| Rate for Payer: Global Benefits Group Commercial |
$100.77
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$125.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$112.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.31
|
| Rate for Payer: Multiplan Commercial |
$134.36
|
| Rate for Payer: Networks By Design Commercial |
$109.17
|
| Rate for Payer: Prime Health Services Commercial |
$142.76
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$100.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$100.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$100.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$83.98
|
| Rate for Payer: United Healthcare All Other HMO |
$83.98
|
| Rate for Payer: United Healthcare HMO Rider |
$83.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$83.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$142.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$142.76
|
| Rate for Payer: Vantage Medical Group Senior |
$142.76
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM [10478]
|
Facility
OP
|
$1.23
|
|
|
Service Code
|
NDC 51079-623-82
|
| Hospital Charge Code |
1743480
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.73
|
| Rate for Payer: BCBS Transplant Transplant |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.86
|
| Rate for Payer: Cigna of CA PPO |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Media |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.80
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.74
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO |
$0.62
|
| Rate for Payer: United Healthcare HMO Rider |
$0.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM [10478]
|
Facility
IP
|
$1.28
|
|
|
Service Code
|
NDC 51079-623-81
|
| Hospital Charge Code |
NDG10478
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.90
|
| Rate for Payer: Cigna of CA PPO |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Galaxy Health WC |
$1.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: Networks By Design Commercial |
$0.83
|
| Rate for Payer: Prime Health Services Commercial |
$1.09
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM [10478]
|
Facility
OP
|
$1.28
|
|
|
Service Code
|
NDC 51079-623-81
|
| Hospital Charge Code |
NDG10478
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.76
|
| Rate for Payer: BCBS Transplant Transplant |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.90
|
| Rate for Payer: Cigna of CA PPO |
$0.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.09
|
| Rate for Payer: Dignity Health Media |
$1.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.51
|
| Rate for Payer: Galaxy Health WC |
$1.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.77
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: Networks By Design Commercial |
$0.83
|
| Rate for Payer: Prime Health Services Commercial |
$1.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.64
|
| Rate for Payer: United Healthcare All Other HMO |
$0.64
|
| Rate for Payer: United Healthcare HMO Rider |
$0.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Vantage Medical Group Senior |
$1.09
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM [10478]
|
Facility
IP
|
$1.23
|
|
|
Service Code
|
NDC 51079-623-82
|
| Hospital Charge Code |
1743480
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.86
|
| Rate for Payer: Cigna of CA PPO |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.80
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
|
|
MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 6858500575
|
| Hospital Charge Code |
1712587
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| 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 |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 6858500575
|
| Hospital Charge Code |
1712587
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| 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 |
$0.06
|
| Rate for Payer: BCBS Transplant Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| 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 |
$0.06
|
| 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 |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| 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 |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| 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
|
|
