|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 7071011573
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Central Health Plan Commercial |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
| Rate for Payer: Riverside University Health System MISP |
$0.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare HMO Rider |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 7071011573
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Central Health Plan Commercial |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$3.32
|
|
|
Service Code
|
NDC 6050525031
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California Commercial |
$2.66
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Central Health Plan Commercial |
$2.66
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Senior |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 2315504403
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.51
|
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Central Health Plan Commercial |
$0.70
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.75
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Senior |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.75
|
| Rate for Payer: Riverside University Health System MISP |
$0.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.75
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$3.32
|
|
|
Service Code
|
NDC 6050525031
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.93
|
| Rate for Payer: Blue Shield of California Commercial |
$2.10
|
| Rate for Payer: Blue Shield of California EPN |
$1.32
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Central Health Plan Commercial |
$2.66
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.82
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Senior |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.32
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
| Rate for Payer: Riverside University Health System MISP |
$1.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.66
|
| Rate for Payer: United Healthcare All Other HMO |
$1.66
|
| Rate for Payer: United Healthcare HMO Rider |
$1.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Vantage Medical Group Senior |
$2.82
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 6233206230
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Central Health Plan Commercial |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 6233206230
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Central Health Plan Commercial |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
| Rate for Payer: Riverside University Health System MISP |
$0.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare HMO Rider |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 2315504403
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Central Health Plan Commercial |
$0.70
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Senior |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.75
|
|
|
LENGTHENING OR SHORTENING OF FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 25280
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$119.75 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,208.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,208.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,924.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$6,568.63
|
| Rate for Payer: Blue Shield of California Commercial |
$6,228.07
|
| Rate for Payer: Blue Shield of California EPN |
$3,914.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,629.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,208.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,943.76
|
| Rate for Payer: EPIC Health Plan Senior |
$4,629.17
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,901.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$119.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$132.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,891.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,639.18
|
| Rate for Payer: Multiplan WC |
$6,568.63
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Preferred Health Network WC |
$6,702.68
|
| Rate for Payer: Prime Health Services Medicare |
$4,460.84
|
| Rate for Payer: Prime Health Services WC |
$6,501.60
|
| Rate for Payer: Riverside University Health System MISP |
$4,629.17
|
| Rate for Payer: United Healthcare All Other HMO |
$20,902.00
|
| Rate for Payer: United Healthcare HMO Rider |
$13,066.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,971.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,208.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4,208.34
|
|
|
LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 27685
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$507.80 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,208.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,208.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,074.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$6,568.63
|
| Rate for Payer: Blue Shield of California Commercial |
$5,036.70
|
| Rate for Payer: Blue Shield of California EPN |
$3,165.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,629.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,208.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,943.76
|
| Rate for Payer: EPIC Health Plan Senior |
$4,629.17
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,901.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$507.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$560.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,891.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,639.18
|
| Rate for Payer: Multiplan WC |
$6,568.63
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Preferred Health Network WC |
$6,702.68
|
| Rate for Payer: Prime Health Services Medicare |
$4,460.84
|
| Rate for Payer: Prime Health Services WC |
$6,501.60
|
| Rate for Payer: Riverside University Health System MISP |
$4,629.17
|
| Rate for Payer: United Healthcare All Other HMO |
$20,902.00
|
| Rate for Payer: United Healthcare HMO Rider |
$13,066.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,971.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,208.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4,208.34
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
OP
|
$19.44
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$17.50 |
| Rate for Payer: Adventist Health Commercial |
$3.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.58
|
| Rate for Payer: Blue Shield of California Commercial |
$12.32
|
| Rate for Payer: Blue Shield of California EPN |
$7.76
|
| Rate for Payer: Cash Price |
$8.75
|
| Rate for Payer: Central Health Plan Commercial |
$15.55
|
| Rate for Payer: Cigna of CA HMO |
$13.61
|
| Rate for Payer: Cigna of CA PPO |
$13.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$13.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.78
|
| Rate for Payer: EPIC Health Plan Senior |
$7.78
|
| Rate for Payer: Galaxy Health WC |
$16.52
|
| Rate for Payer: Global Benefits Group Commercial |
$11.66
|
| Rate for Payer: Health Management Network EPO/PPO |
$17.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13.61
|
| Rate for Payer: Multiplan Commercial |
$14.58
|
| Rate for Payer: Networks By Design Commercial |
$9.72
|
| Rate for Payer: Prime Health Services Commercial |
$16.52
|
| Rate for Payer: Riverside University Health System MISP |
$7.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.30
|
| Rate for Payer: United Healthcare All Other HMO |
$7.10
|
| Rate for Payer: United Healthcare HMO Rider |
$6.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.52
|
| Rate for Payer: Vantage Medical Group Senior |
$16.52
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
IP
|
$19.44
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$17.50 |
| Rate for Payer: Adventist Health Commercial |
$3.89
|
| Rate for Payer: Blue Shield of California Commercial |
$15.59
|
| Rate for Payer: Blue Shield of California EPN |
$9.80
|
| Rate for Payer: Cash Price |
$8.75
|
| Rate for Payer: Central Health Plan Commercial |
$15.55
|
| Rate for Payer: Cigna of CA HMO |
$13.61
|
| Rate for Payer: Cigna of CA PPO |
$13.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$13.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.78
|
| Rate for Payer: EPIC Health Plan Senior |
$7.78
|
| Rate for Payer: Galaxy Health WC |
$16.52
|
| Rate for Payer: Global Benefits Group Commercial |
$11.66
|
| Rate for Payer: Health Management Network EPO/PPO |
$17.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.89
|
| Rate for Payer: Multiplan Commercial |
$14.58
|
| Rate for Payer: Networks By Design Commercial |
$9.72
|
| Rate for Payer: Prime Health Services Commercial |
$16.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.30
|
| Rate for Payer: United Healthcare All Other HMO |
$7.10
|
| Rate for Payer: United Healthcare HMO Rider |
$6.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.37
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
OP
|
$337.50
|
|
|
Service Code
|
NDC 0006307604
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.50 |
| Max. Negotiated Rate |
$303.75 |
| Rate for Payer: Adventist Health Commercial |
$67.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$204.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$286.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$185.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$253.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$163.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$196.32
|
| Rate for Payer: Blue Shield of California Commercial |
$213.97
|
| Rate for Payer: Blue Shield of California EPN |
$134.66
|
| Rate for Payer: Cash Price |
$151.88
|
| Rate for Payer: Central Health Plan Commercial |
$270.00
|
| Rate for Payer: Cigna of CA HMO |
$236.25
|
| Rate for Payer: Cigna of CA PPO |
$236.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$286.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$286.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$286.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$236.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.00
|
| Rate for Payer: EPIC Health Plan Senior |
$135.00
|
| Rate for Payer: Galaxy Health WC |
$286.88
|
| Rate for Payer: Global Benefits Group Commercial |
$202.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$303.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$214.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$122.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$199.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$236.25
|
| Rate for Payer: Multiplan Commercial |
$253.12
|
| Rate for Payer: Networks By Design Commercial |
$219.38
|
| Rate for Payer: Prime Health Services Commercial |
$286.88
|
| Rate for Payer: Riverside University Health System MISP |
$135.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$202.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$202.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$168.75
|
| Rate for Payer: United Healthcare All Other HMO |
$168.75
|
| Rate for Payer: United Healthcare HMO Rider |
$168.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$168.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$286.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$286.88
|
| Rate for Payer: Vantage Medical Group Senior |
$286.88
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
OP
|
$337.50
|
|
|
Service Code
|
NDC 0006307603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.50 |
| Max. Negotiated Rate |
$303.75 |
| Rate for Payer: Adventist Health Commercial |
$67.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$204.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$286.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$185.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$253.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$163.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$196.32
|
| Rate for Payer: Blue Shield of California Commercial |
$213.97
|
| Rate for Payer: Blue Shield of California EPN |
$134.66
|
| Rate for Payer: Cash Price |
$151.88
|
| Rate for Payer: Central Health Plan Commercial |
$270.00
|
| Rate for Payer: Cigna of CA HMO |
$236.25
|
| Rate for Payer: Cigna of CA PPO |
$236.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$286.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$286.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$286.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$236.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.00
|
| Rate for Payer: EPIC Health Plan Senior |
$135.00
|
| Rate for Payer: Galaxy Health WC |
$286.88
|
| Rate for Payer: Global Benefits Group Commercial |
$202.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$303.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$214.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$122.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$199.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$236.25
|
| Rate for Payer: Multiplan Commercial |
$253.12
|
| Rate for Payer: Networks By Design Commercial |
$219.38
|
| Rate for Payer: Prime Health Services Commercial |
$286.88
|
| Rate for Payer: Riverside University Health System MISP |
$135.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$202.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$202.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$168.75
|
| Rate for Payer: United Healthcare All Other HMO |
$168.75
|
| Rate for Payer: United Healthcare HMO Rider |
$168.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$168.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$286.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$286.88
|
| Rate for Payer: Vantage Medical Group Senior |
$286.88
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
IP
|
$337.50
|
|
|
Service Code
|
NDC 0006307603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.50 |
| Max. Negotiated Rate |
$303.75 |
| Rate for Payer: Adventist Health Commercial |
$67.50
|
| Rate for Payer: Blue Shield of California Commercial |
$270.68
|
| Rate for Payer: Blue Shield of California EPN |
$170.10
|
| Rate for Payer: Cash Price |
$151.88
|
| Rate for Payer: Central Health Plan Commercial |
$270.00
|
| Rate for Payer: Cigna of CA HMO |
$236.25
|
| Rate for Payer: Cigna of CA PPO |
$236.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$236.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.00
|
| Rate for Payer: EPIC Health Plan Senior |
$135.00
|
| Rate for Payer: Galaxy Health WC |
$286.88
|
| Rate for Payer: Global Benefits Group Commercial |
$202.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$303.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$214.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$199.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.50
|
| Rate for Payer: Multiplan Commercial |
$253.12
|
| Rate for Payer: Networks By Design Commercial |
$219.38
|
| Rate for Payer: Prime Health Services Commercial |
$286.88
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
IP
|
$337.50
|
|
|
Service Code
|
NDC 0006307604
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.50 |
| Max. Negotiated Rate |
$303.75 |
| Rate for Payer: Adventist Health Commercial |
$67.50
|
| Rate for Payer: Blue Shield of California Commercial |
$270.68
|
| Rate for Payer: Blue Shield of California EPN |
$170.10
|
| Rate for Payer: Cash Price |
$151.88
|
| Rate for Payer: Central Health Plan Commercial |
$270.00
|
| Rate for Payer: Cigna of CA HMO |
$236.25
|
| Rate for Payer: Cigna of CA PPO |
$236.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$236.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.00
|
| Rate for Payer: EPIC Health Plan Senior |
$135.00
|
| Rate for Payer: Galaxy Health WC |
$286.88
|
| Rate for Payer: Global Benefits Group Commercial |
$202.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$303.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$214.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$199.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.50
|
| Rate for Payer: Multiplan Commercial |
$253.12
|
| Rate for Payer: Networks By Design Commercial |
$219.38
|
| Rate for Payer: Prime Health Services Commercial |
$286.88
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 5026847615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Riverside University Health System MISP |
$0.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 5026847615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 1672903410
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| 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 Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Riverside University Health System MISP |
$0.12
|
| 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
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 5026847611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 5026847611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Riverside University Health System MISP |
$0.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 1672903410
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$21.60 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Adventist Health Commercial |
$3.84
|
| Rate for Payer: Blue Shield of California Commercial |
$19.25
|
| Rate for Payer: Blue Shield of California Commercial |
$15.40
|
| Rate for Payer: Blue Shield of California EPN |
$9.68
|
| Rate for Payer: Blue Shield of California EPN |
$12.10
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Central Health Plan Commercial |
$19.20
|
| Rate for Payer: Central Health Plan Commercial |
$15.36
|
| Rate for Payer: Cigna of CA HMO |
$13.44
|
| Rate for Payer: Cigna of CA HMO |
$16.80
|
| Rate for Payer: Cigna of CA PPO |
$13.44
|
| Rate for Payer: Cigna of CA PPO |
$16.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$13.44
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$16.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.60
|
| Rate for Payer: EPIC Health Plan Senior |
$7.68
|
| Rate for Payer: EPIC Health Plan Senior |
$9.60
|
| Rate for Payer: Galaxy Health WC |
$20.40
|
| Rate for Payer: Galaxy Health WC |
$16.32
|
| Rate for Payer: Global Benefits Group Commercial |
$11.52
|
| Rate for Payer: Global Benefits Group Commercial |
$14.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$17.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$21.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$15.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.84
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Networks By Design Commercial |
$9.60
|
| Rate for Payer: Networks By Design Commercial |
$12.00
|
| Rate for Payer: Prime Health Services Commercial |
$20.40
|
| Rate for Payer: Prime Health Services Commercial |
$16.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.01
|
| Rate for Payer: United Healthcare All Other HMO |
$8.77
|
| Rate for Payer: United Healthcare All Other HMO |
$7.01
|
| Rate for Payer: United Healthcare HMO Rider |
$6.86
|
| Rate for Payer: United Healthcare HMO Rider |
$8.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.86
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]
|
Facility
|
OP
|
$19.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.93 |
| Max. Negotiated Rate |
$49.62 |
| Rate for Payer: Adventist Health Commercial |
$3.84
|
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$21.78
|
| Rate for Payer: Aetna of CA HMO/PPO |
$21.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$39.77
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$39.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$49.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$49.62
|
| Rate for Payer: Blue Shield of California Commercial |
$10.89
|
| Rate for Payer: Blue Shield of California Commercial |
$10.89
|
| Rate for Payer: Blue Shield of California EPN |
$9.90
|
| Rate for Payer: Blue Shield of California EPN |
$9.90
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Central Health Plan Commercial |
$15.36
|
| Rate for Payer: Central Health Plan Commercial |
$19.20
|
| Rate for Payer: Cigna of CA HMO |
$13.44
|
| Rate for Payer: Cigna of CA HMO |
$16.80
|
| Rate for Payer: Cigna of CA PPO |
$16.80
|
| Rate for Payer: Cigna of CA PPO |
$13.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$13.44
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$16.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.60
|
| Rate for Payer: EPIC Health Plan Senior |
$7.68
|
| Rate for Payer: EPIC Health Plan Senior |
$9.60
|
| Rate for Payer: Galaxy Health WC |
$20.40
|
| Rate for Payer: Galaxy Health WC |
$16.32
|
| Rate for Payer: Global Benefits Group Commercial |
$11.52
|
| Rate for Payer: Global Benefits Group Commercial |
$14.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$17.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$21.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$2.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$2.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$15.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.80
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: Networks By Design Commercial |
$12.00
|
| Rate for Payer: Networks By Design Commercial |
$9.60
|
| Rate for Payer: Prime Health Services Commercial |
$16.32
|
| Rate for Payer: Prime Health Services Commercial |
$20.40
|
| Rate for Payer: Riverside University Health System MISP |
$9.60
|
| Rate for Payer: Riverside University Health System MISP |
$7.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$14.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.01
|
| Rate for Payer: United Healthcare All Other HMO |
$8.77
|
| Rate for Payer: United Healthcare All Other HMO |
$7.01
|
| Rate for Payer: United Healthcare HMO Rider |
$6.86
|
| Rate for Payer: United Healthcare HMO Rider |
$8.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$16.32
|
|
|
LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [15370]
|
Facility
|
IP
|
$2.84
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.43
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Central Health Plan Commercial |
$2.27
|
| Rate for Payer: Cigna of CA HMO |
$1.99
|
| Rate for Payer: Cigna of CA PPO |
$1.99
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: EPIC Health Plan Senior |
$1.14
|
| Rate for Payer: Galaxy Health WC |
$2.41
|
| Rate for Payer: Global Benefits Group Commercial |
$1.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
| Rate for Payer: Networks By Design Commercial |
$1.42
|
| Rate for Payer: Prime Health Services Commercial |
$2.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.07
|
| Rate for Payer: United Healthcare All Other HMO |
$1.04
|
| Rate for Payer: United Healthcare HMO Rider |
$1.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.93
|
|
