|
LUBIPROSTONE 8 MCG CAPSULE [91534]
|
Facility
|
IP
|
$7.42
|
|
|
Service Code
|
NDC 6476408060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$6.68 |
| Rate for Payer: Adventist Health Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California Commercial |
$5.95
|
| Rate for Payer: Blue Shield of California EPN |
$3.74
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Central Health Plan Commercial |
$5.94
|
| Rate for Payer: Cigna of CA HMO |
$5.19
|
| Rate for Payer: Cigna of CA PPO |
$5.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.97
|
| Rate for Payer: EPIC Health Plan Senior |
$2.97
|
| Rate for Payer: Galaxy Health WC |
$6.31
|
| Rate for Payer: Global Benefits Group Commercial |
$4.45
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$5.57
|
| Rate for Payer: Networks By Design Commercial |
$4.82
|
| Rate for Payer: Prime Health Services Commercial |
$6.31
|
|
|
LUBIPROSTONE 8 MCG CAPSULE [91534]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 0254302802
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
LUNG TRANSPLANT
|
Facility
|
IP
|
$340,836.31
|
|
|
Service Code
|
MSDRG 007
|
| Min. Negotiated Rate |
$179,511.37 |
| Max. Negotiated Rate |
$340,836.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$340,836.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$220,166.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$308,240.66
|
| Rate for Payer: CareMore Health Medicare Advantage |
$179,511.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$296,193.76
|
| Rate for Payer: EPIC Health Plan Senior |
$197,462.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$179,511.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$251,315.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$240,545.24
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$179,511.37
|
| Rate for Payer: Prime Health Services Medicare |
$190,282.05
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 6068774711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.97
|
| Rate for Payer: Blue Shield of California Commercial |
$3.24
|
| Rate for Payer: Blue Shield of California EPN |
$2.04
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Central Health Plan Commercial |
$4.09
|
| Rate for Payer: Cigna of CA HMO |
$3.58
|
| Rate for Payer: Cigna of CA PPO |
$3.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: EPIC Health Plan Senior |
$2.04
|
| Rate for Payer: Galaxy Health WC |
$4.34
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
| Rate for Payer: Networks By Design Commercial |
$3.32
|
| Rate for Payer: Prime Health Services Commercial |
$4.34
|
| Rate for Payer: Riverside University Health System MISP |
$2.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.07
|
| 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 |
$4.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.34
|
| Rate for Payer: Vantage Medical Group Senior |
$4.34
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 6068774721
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Blue Shield of California Commercial |
$4.10
|
| Rate for Payer: Blue Shield of California EPN |
$2.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Central Health Plan Commercial |
$4.09
|
| Rate for Payer: Cigna of CA HMO |
$3.58
|
| Rate for Payer: Cigna of CA PPO |
$3.58
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: EPIC Health Plan Senior |
$2.04
|
| Rate for Payer: Galaxy Health WC |
$4.34
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
| Rate for Payer: Networks By Design Commercial |
$3.32
|
| Rate for Payer: Prime Health Services Commercial |
$4.34
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 6068774711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Blue Shield of California Commercial |
$4.10
|
| Rate for Payer: Blue Shield of California EPN |
$2.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Central Health Plan Commercial |
$4.09
|
| Rate for Payer: Cigna of CA HMO |
$3.58
|
| Rate for Payer: Cigna of CA PPO |
$3.58
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: EPIC Health Plan Senior |
$2.04
|
| Rate for Payer: Galaxy Health WC |
$4.34
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
| Rate for Payer: Networks By Design Commercial |
$3.32
|
| Rate for Payer: Prime Health Services Commercial |
$4.34
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 4733557883
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 6068774721
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.97
|
| Rate for Payer: Blue Shield of California Commercial |
$3.24
|
| Rate for Payer: Blue Shield of California EPN |
$2.04
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Central Health Plan Commercial |
$4.09
|
| Rate for Payer: Cigna of CA HMO |
$3.58
|
| Rate for Payer: Cigna of CA PPO |
$3.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: EPIC Health Plan Senior |
$2.04
|
| Rate for Payer: Galaxy Health WC |
$4.34
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
| Rate for Payer: Networks By Design Commercial |
$3.32
|
| Rate for Payer: Prime Health Services Commercial |
$4.34
|
| Rate for Payer: Riverside University Health System MISP |
$2.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.07
|
| 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 |
$4.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.34
|
| Rate for Payer: Vantage Medical Group Senior |
$4.34
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 4733557883
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Riverside University Health System MISP |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 6068775821
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.98
|
| Rate for Payer: Blue Shield of California Commercial |
$3.25
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Central Health Plan Commercial |
$4.10
|
| 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 Medi-Cal |
$4.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Senior |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.59
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
| Rate for Payer: Riverside University Health System MISP |
$2.05
|
| 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
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 6068775821
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California Commercial |
$4.11
|
| Rate for Payer: Blue Shield of California EPN |
$2.59
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Central Health Plan Commercial |
$4.10
|
| Rate for Payer: Cigna of CA HMO |
$3.59
|
| Rate for Payer: Cigna of CA PPO |
$3.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Senior |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
| 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
|
$0.80
|
|
|
Service Code
|
NDC 4733568483
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$58.45
|
|
|
Service Code
|
NDC 6340230430
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.69 |
| Max. Negotiated Rate |
$52.60 |
| Rate for Payer: Adventist Health Commercial |
$11.69
|
| Rate for Payer: Blue Shield of California Commercial |
$46.88
|
| Rate for Payer: Blue Shield of California EPN |
$29.46
|
| Rate for Payer: Cash Price |
$26.30
|
| Rate for Payer: Central Health Plan Commercial |
$46.76
|
| Rate for Payer: Cigna of CA HMO |
$40.91
|
| Rate for Payer: Cigna of CA PPO |
$40.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$40.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.38
|
| Rate for Payer: EPIC Health Plan Senior |
$23.38
|
| Rate for Payer: Galaxy Health WC |
$49.68
|
| Rate for Payer: Global Benefits Group Commercial |
$35.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$52.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$37.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$34.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.69
|
| Rate for Payer: Multiplan Commercial |
$43.84
|
| Rate for Payer: Networks By Design Commercial |
$37.99
|
| Rate for Payer: Prime Health Services Commercial |
$49.68
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 6068775811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.98
|
| Rate for Payer: Blue Shield of California Commercial |
$3.25
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Central Health Plan Commercial |
$4.10
|
| 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 Medi-Cal |
$4.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Senior |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.59
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
| Rate for Payer: Riverside University Health System MISP |
$2.05
|
| 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
|
$0.80
|
|
|
Service Code
|
NDC 4733568483
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Riverside University Health System MISP |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$58.45
|
|
|
Service Code
|
NDC 6340230430
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.69 |
| Max. Negotiated Rate |
$52.60 |
| Rate for Payer: Adventist Health Commercial |
$11.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$35.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$49.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$43.84
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$28.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34.00
|
| Rate for Payer: Blue Shield of California Commercial |
$37.06
|
| Rate for Payer: Blue Shield of California EPN |
$23.32
|
| Rate for Payer: Cash Price |
$26.30
|
| Rate for Payer: Central Health Plan Commercial |
$46.76
|
| Rate for Payer: Cigna of CA HMO |
$40.91
|
| Rate for Payer: Cigna of CA PPO |
$40.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$49.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$49.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$40.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.38
|
| Rate for Payer: EPIC Health Plan Senior |
$23.38
|
| Rate for Payer: Galaxy Health WC |
$49.68
|
| Rate for Payer: Global Benefits Group Commercial |
$35.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$52.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$37.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$34.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$40.91
|
| Rate for Payer: Multiplan Commercial |
$43.84
|
| Rate for Payer: Networks By Design Commercial |
$37.99
|
| Rate for Payer: Prime Health Services Commercial |
$49.68
|
| Rate for Payer: Riverside University Health System MISP |
$23.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$29.23
|
| Rate for Payer: United Healthcare All Other HMO |
$29.23
|
| Rate for Payer: United Healthcare HMO Rider |
$29.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$49.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$49.68
|
| Rate for Payer: Vantage Medical Group Senior |
$49.68
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 6068775811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California Commercial |
$4.11
|
| Rate for Payer: Blue Shield of California EPN |
$2.59
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Central Health Plan Commercial |
$4.10
|
| Rate for Payer: Cigna of CA HMO |
$3.59
|
| Rate for Payer: Cigna of CA PPO |
$3.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Senior |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
|
|
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [228261]
|
Facility
|
OP
|
$10,092.00
|
|
|
Service Code
|
HCPCS J9223
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$215.95 |
| Max. Negotiated Rate |
$9,082.80 |
| Rate for Payer: Adventist Health Commercial |
$2,018.40
|
| Rate for Payer: Adventist Health Medi-Cal |
$215.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$403.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$323.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$237.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$215.95
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$328.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$409.47
|
| Rate for Payer: Blue Shield of California Commercial |
$264.99
|
| Rate for Payer: Blue Shield of California EPN |
$240.90
|
| Rate for Payer: Cash Price |
$4,541.40
|
| Rate for Payer: Cash Price |
$4,541.40
|
| Rate for Payer: Central Health Plan Commercial |
$8,073.60
|
| Rate for Payer: Cigna of CA HMO |
$7,064.40
|
| Rate for Payer: Cigna of CA PPO |
$7,064.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$269.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$237.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$237.54
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7,064.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$356.32
|
| Rate for Payer: EPIC Health Plan Senior |
$237.54
|
| Rate for Payer: Galaxy Health WC |
$8,578.20
|
| Rate for Payer: Global Benefits Group Commercial |
$6,055.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$9,082.80
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$354.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$215.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$215.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$6,408.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$400.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$302.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,018.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$289.37
|
| Rate for Payer: Multiplan Commercial |
$7,569.00
|
| Rate for Payer: Networks By Design Commercial |
$5,046.00
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$215.95
|
| Rate for Payer: Prime Health Services Commercial |
$8,578.20
|
| Rate for Payer: Prime Health Services Medicare |
$228.91
|
| Rate for Payer: Riverside University Health System MISP |
$237.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6,055.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6,055.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,787.53
|
| Rate for Payer: United Healthcare All Other HMO |
$3,686.61
|
| Rate for Payer: United Healthcare HMO Rider |
$3,606.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,305.13
|
| Rate for Payer: Upland Medical Group Pediatric |
$215.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$269.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$237.54
|
| Rate for Payer: Vantage Medical Group Senior |
$237.54
|
|
|
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [228261]
|
Facility
|
IP
|
$10,092.00
|
|
|
Service Code
|
HCPCS J9223
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,018.40 |
| Max. Negotiated Rate |
$9,082.80 |
| Rate for Payer: Adventist Health Commercial |
$2,018.40
|
| Rate for Payer: Blue Shield of California Commercial |
$8,093.78
|
| Rate for Payer: Blue Shield of California EPN |
$5,086.37
|
| Rate for Payer: Cash Price |
$4,541.40
|
| Rate for Payer: Central Health Plan Commercial |
$8,073.60
|
| Rate for Payer: Cigna of CA HMO |
$7,064.40
|
| Rate for Payer: Cigna of CA PPO |
$7,064.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7,064.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,036.80
|
| Rate for Payer: EPIC Health Plan Senior |
$4,036.80
|
| Rate for Payer: Galaxy Health WC |
$8,578.20
|
| Rate for Payer: Global Benefits Group Commercial |
$6,055.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$9,082.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$6,408.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,954.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,018.40
|
| Rate for Payer: Multiplan Commercial |
$7,569.00
|
| Rate for Payer: Networks By Design Commercial |
$5,046.00
|
| Rate for Payer: Prime Health Services Commercial |
$8,578.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,787.53
|
| Rate for Payer: United Healthcare All Other HMO |
$3,686.61
|
| Rate for Payer: United Healthcare HMO Rider |
$3,606.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,305.13
|
|
|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [225877]
|
Facility
|
IP
|
$5,034.48
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,006.90 |
| Max. Negotiated Rate |
$4,531.03 |
| Rate for Payer: Adventist Health Commercial |
$1,006.90
|
| Rate for Payer: Blue Shield of California Commercial |
$4,037.65
|
| Rate for Payer: Blue Shield of California EPN |
$2,537.38
|
| Rate for Payer: Cash Price |
$2,265.52
|
| Rate for Payer: Central Health Plan Commercial |
$4,027.58
|
| Rate for Payer: Cigna of CA HMO |
$3,524.14
|
| Rate for Payer: Cigna of CA PPO |
$3,524.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,524.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,013.79
|
| Rate for Payer: EPIC Health Plan Senior |
$2,013.79
|
| Rate for Payer: Galaxy Health WC |
$4,279.31
|
| Rate for Payer: Global Benefits Group Commercial |
$3,020.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$4,531.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3,196.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,970.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,006.90
|
| Rate for Payer: Multiplan Commercial |
$3,775.86
|
| Rate for Payer: Networks By Design Commercial |
$2,517.24
|
| Rate for Payer: Prime Health Services Commercial |
$4,279.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,889.44
|
| Rate for Payer: United Healthcare All Other HMO |
$1,839.10
|
| Rate for Payer: United Healthcare HMO Rider |
$1,799.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,648.79
|
|
|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [225877]
|
Facility
|
OP
|
$5,034.48
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.51 |
| Max. Negotiated Rate |
$4,531.03 |
| Rate for Payer: Adventist Health Commercial |
$1,006.90
|
| Rate for Payer: Adventist Health Medi-Cal |
$43.51
|
| Rate for Payer: Aetna of CA HMO/PPO |
$255.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$47.86
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$69.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$86.26
|
| Rate for Payer: Blue Shield of California Commercial |
$52.18
|
| Rate for Payer: Blue Shield of California EPN |
$47.44
|
| Rate for Payer: Cash Price |
$2,265.52
|
| Rate for Payer: Cash Price |
$2,265.52
|
| Rate for Payer: Central Health Plan Commercial |
$4,027.58
|
| Rate for Payer: Cigna of CA HMO |
$3,524.14
|
| Rate for Payer: Cigna of CA PPO |
$3,524.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$47.86
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,524.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.79
|
| Rate for Payer: EPIC Health Plan Senior |
$47.86
|
| Rate for Payer: Galaxy Health WC |
$4,279.31
|
| Rate for Payer: Global Benefits Group Commercial |
$3,020.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$4,531.03
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$71.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$43.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.51
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3,196.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$89.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$60.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,006.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$58.30
|
| Rate for Payer: Multiplan Commercial |
$3,775.86
|
| Rate for Payer: Networks By Design Commercial |
$2,517.24
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$43.51
|
| Rate for Payer: Prime Health Services Commercial |
$4,279.31
|
| Rate for Payer: Prime Health Services Medicare |
$46.12
|
| Rate for Payer: Riverside University Health System MISP |
$47.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,020.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,020.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,889.44
|
| Rate for Payer: United Healthcare All Other HMO |
$1,839.10
|
| Rate for Payer: United Healthcare HMO Rider |
$1,799.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,648.79
|
| Rate for Payer: Upland Medical Group Pediatric |
$43.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.86
|
| Rate for Payer: Vantage Medical Group Senior |
$47.86
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [225879]
|
Facility
|
OP
|
$15,103.39
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.51 |
| Max. Negotiated Rate |
$13,593.05 |
| Rate for Payer: Adventist Health Commercial |
$3,020.68
|
| Rate for Payer: Adventist Health Medi-Cal |
$43.51
|
| Rate for Payer: Aetna of CA HMO/PPO |
$255.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$47.86
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$69.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$86.26
|
| Rate for Payer: Blue Shield of California Commercial |
$52.18
|
| Rate for Payer: Blue Shield of California EPN |
$47.44
|
| Rate for Payer: Cash Price |
$6,796.53
|
| Rate for Payer: Cash Price |
$6,796.53
|
| Rate for Payer: Central Health Plan Commercial |
$12,082.71
|
| Rate for Payer: Cigna of CA HMO |
$10,572.37
|
| Rate for Payer: Cigna of CA PPO |
$10,572.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$47.86
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10,572.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.79
|
| Rate for Payer: EPIC Health Plan Senior |
$47.86
|
| Rate for Payer: Galaxy Health WC |
$12,837.88
|
| Rate for Payer: Global Benefits Group Commercial |
$9,062.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$13,593.05
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$71.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$43.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.51
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9,590.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$89.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$60.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,020.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$58.30
|
| Rate for Payer: Multiplan Commercial |
$11,327.54
|
| Rate for Payer: Networks By Design Commercial |
$7,551.69
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$43.51
|
| Rate for Payer: Prime Health Services Commercial |
$12,837.88
|
| Rate for Payer: Prime Health Services Medicare |
$46.12
|
| Rate for Payer: Riverside University Health System MISP |
$47.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9,062.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9,062.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,668.30
|
| Rate for Payer: United Healthcare All Other HMO |
$5,517.27
|
| Rate for Payer: United Healthcare HMO Rider |
$5,397.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,946.36
|
| Rate for Payer: Upland Medical Group Pediatric |
$43.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.86
|
| Rate for Payer: Vantage Medical Group Senior |
$47.86
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [225879]
|
Facility
|
IP
|
$15,103.39
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,020.68 |
| Max. Negotiated Rate |
$13,593.05 |
| Rate for Payer: Adventist Health Commercial |
$3,020.68
|
| Rate for Payer: Blue Shield of California Commercial |
$12,112.92
|
| Rate for Payer: Blue Shield of California EPN |
$7,612.11
|
| Rate for Payer: Cash Price |
$6,796.53
|
| Rate for Payer: Central Health Plan Commercial |
$12,082.71
|
| Rate for Payer: Cigna of CA HMO |
$10,572.37
|
| Rate for Payer: Cigna of CA PPO |
$10,572.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10,572.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,041.36
|
| Rate for Payer: EPIC Health Plan Senior |
$6,041.36
|
| Rate for Payer: Galaxy Health WC |
$12,837.88
|
| Rate for Payer: Global Benefits Group Commercial |
$9,062.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$13,593.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9,590.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8,911.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,020.68
|
| Rate for Payer: Multiplan Commercial |
$11,327.54
|
| Rate for Payer: Networks By Design Commercial |
$7,551.69
|
| Rate for Payer: Prime Health Services Commercial |
$12,837.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,668.30
|
| Rate for Payer: United Healthcare All Other HMO |
$5,517.27
|
| Rate for Payer: United Healthcare HMO Rider |
$5,397.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,946.36
|
|
|
LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [220890]
|
Facility
|
IP
|
$58,680.00
|
|
|
Service Code
|
HCPCS A9513
|
| Hospital Charge Code |
901700056
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$11,736.00 |
| Max. Negotiated Rate |
$52,812.00 |
| Rate for Payer: Adventist Health Commercial |
$11,736.00
|
| Rate for Payer: Blue Shield of California Commercial |
$47,061.36
|
| Rate for Payer: Blue Shield of California EPN |
$29,574.72
|
| Rate for Payer: Cash Price |
$26,406.00
|
| Rate for Payer: Central Health Plan Commercial |
$46,944.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$41,076.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$23,472.00
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Health Management Network EPO/PPO |
$52,812.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$37,261.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$34,621.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11,736.00
|
| Rate for Payer: Multiplan Commercial |
$44,010.00
|
| Rate for Payer: Networks By Design Commercial |
$38,142.00
|
| Rate for Payer: Prime Health Services Commercial |
$49,878.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$22,022.60
|
| Rate for Payer: United Healthcare All Other HMO |
$21,435.80
|
| Rate for Payer: United Healthcare HMO Rider |
$20,972.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19,217.70
|
|
|
LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [220890]
|
Facility
|
OP
|
$58,680.00
|
|
|
Service Code
|
HCPCS A9513
|
| Hospital Charge Code |
901700056
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$350.21 |
| Max. Negotiated Rate |
$52,812.00 |
| Rate for Payer: Adventist Health Commercial |
$11,736.00
|
| Rate for Payer: Adventist Health Medi-Cal |
$350.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$580.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$437.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$385.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$385.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$470.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$586.56
|
| Rate for Payer: Blue Shield of California Commercial |
$36,968.40
|
| Rate for Payer: Blue Shield of California EPN |
$23,295.96
|
| Rate for Payer: Cash Price |
$26,406.00
|
| Rate for Payer: Cash Price |
$26,406.00
|
| Rate for Payer: Central Health Plan Commercial |
$46,944.00
|
| 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 |
$437.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$385.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$385.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$41,076.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$577.85
|
| Rate for Payer: EPIC Health Plan Senior |
$385.23
|
| Rate for Payer: Galaxy Health WC |
$49,878.00
|
| Rate for Payer: Global Benefits Group Commercial |
$35,208.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$52,812.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$574.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$524.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$350.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$37,261.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$579.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$490.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11,736.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$469.28
|
| Rate for Payer: Multiplan Commercial |
$44,010.00
|
| Rate for Payer: Networks By Design Commercial |
$38,142.00
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$350.21
|
| Rate for Payer: Prime Health Services Commercial |
$49,878.00
|
| Rate for Payer: Prime Health Services Medicare |
$371.22
|
| Rate for Payer: Riverside University Health System MISP |
$385.23
|
| 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 |
$22,022.60
|
| Rate for Payer: United Healthcare All Other HMO |
$21,435.80
|
| Rate for Payer: United Healthcare HMO Rider |
$20,972.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19,217.70
|
| Rate for Payer: Upland Medical Group Pediatric |
$350.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$437.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$385.23
|
| Rate for Payer: Vantage Medical Group Senior |
$385.23
|
|
