|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$7.48
|
|
|
Service Code
|
NDC 0054-4497-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$6.73 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$5.78
|
| Rate for Payer: Blue Shield of California EPN |
$3.77
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Central Health Plan Commercial |
$5.98
|
| Rate for Payer: Cigna of CA HMO |
$5.24
|
| Rate for Payer: Cigna of CA PPO |
$5.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.99
|
| Rate for Payer: EPIC Health Plan Senior |
$2.99
|
| Rate for Payer: Galaxy Health WC |
$6.36
|
| Rate for Payer: Global Benefits Group Commercial |
$4.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$5.61
|
| Rate for Payer: Networks By Design Commercial |
$4.86
|
| Rate for Payer: Prime Health Services Commercial |
$6.36
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$6.65
|
|
|
Service Code
|
NDC 0054-4497-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$5.99 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California Commercial |
$5.14
|
| Rate for Payer: Blue Shield of California EPN |
$3.35
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Central Health Plan Commercial |
$5.32
|
| Rate for Payer: Cigna of CA HMO |
$4.66
|
| Rate for Payer: Cigna of CA PPO |
$4.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.66
|
| Rate for Payer: EPIC Health Plan Senior |
$2.66
|
| Rate for Payer: Galaxy Health WC |
$5.65
|
| Rate for Payer: Global Benefits Group Commercial |
$3.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Networks By Design Commercial |
$4.32
|
| Rate for Payer: Prime Health Services Commercial |
$5.65
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$6.65
|
|
|
Service Code
|
NDC 69315-185-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$5.99 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California Commercial |
$5.14
|
| Rate for Payer: Blue Shield of California EPN |
$3.35
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Central Health Plan Commercial |
$5.32
|
| Rate for Payer: Cigna of CA HMO |
$4.66
|
| Rate for Payer: Cigna of CA PPO |
$4.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.66
|
| Rate for Payer: EPIC Health Plan Senior |
$2.66
|
| Rate for Payer: Galaxy Health WC |
$5.65
|
| Rate for Payer: Global Benefits Group Commercial |
$3.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Networks By Design Commercial |
$4.32
|
| Rate for Payer: Prime Health Services Commercial |
$5.65
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 50742-182-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.88
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.47
|
| Rate for Payer: Blue Shield of California Commercial |
$1.53
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Central Health Plan Commercial |
$2.00
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.25
|
| Rate for Payer: InnovAge PACE Commercial |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
| Rate for Payer: Riverside University Health System MISP |
$1.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.25
|
| Rate for Payer: United Healthcare All Other HMO |
$1.25
|
| Rate for Payer: United Healthcare HMO Rider |
$1.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$7.48
|
|
|
Service Code
|
NDC 69315-185-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$6.73 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.61
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.39
|
| Rate for Payer: Blue Shield of California Commercial |
$4.57
|
| Rate for Payer: Blue Shield of California EPN |
$2.98
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Central Health Plan Commercial |
$5.98
|
| Rate for Payer: Cigna of CA HMO |
$5.24
|
| Rate for Payer: Cigna of CA PPO |
$5.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.99
|
| Rate for Payer: EPIC Health Plan Senior |
$2.99
|
| Rate for Payer: Galaxy Health WC |
$6.36
|
| Rate for Payer: Global Benefits Group Commercial |
$4.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.73
|
| Rate for Payer: InnovAge PACE Commercial |
$3.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$5.61
|
| Rate for Payer: Networks By Design Commercial |
$4.86
|
| Rate for Payer: Prime Health Services Commercial |
$6.36
|
| Rate for Payer: Riverside University Health System MISP |
$2.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.74
|
| Rate for Payer: United Healthcare All Other HMO |
$3.74
|
| Rate for Payer: United Healthcare HMO Rider |
$3.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: Vantage Medical Group Senior |
$6.36
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$6.65
|
|
|
Service Code
|
NDC 69315-185-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$5.99 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.99
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.91
|
| Rate for Payer: Blue Shield of California Commercial |
$4.06
|
| Rate for Payer: Blue Shield of California EPN |
$2.65
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Central Health Plan Commercial |
$5.32
|
| Rate for Payer: Cigna of CA HMO |
$4.66
|
| Rate for Payer: Cigna of CA PPO |
$4.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.66
|
| Rate for Payer: EPIC Health Plan Senior |
$2.66
|
| Rate for Payer: Galaxy Health WC |
$5.65
|
| Rate for Payer: Global Benefits Group Commercial |
$3.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.99
|
| Rate for Payer: InnovAge PACE Commercial |
$3.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.66
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Networks By Design Commercial |
$4.32
|
| Rate for Payer: Prime Health Services Commercial |
$5.65
|
| Rate for Payer: Riverside University Health System MISP |
$2.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.33
|
| Rate for Payer: United Healthcare All Other HMO |
$3.33
|
| Rate for Payer: United Healthcare HMO Rider |
$3.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.65
|
| Rate for Payer: Vantage Medical Group Senior |
$5.65
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 50742-182-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.93
|
| Rate for Payer: Blue Shield of California EPN |
$1.26
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Central Health Plan Commercial |
$2.00
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$7.48
|
|
|
Service Code
|
NDC 69315-185-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$6.73 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$5.78
|
| Rate for Payer: Blue Shield of California EPN |
$3.77
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Central Health Plan Commercial |
$5.98
|
| Rate for Payer: Cigna of CA HMO |
$5.24
|
| Rate for Payer: Cigna of CA PPO |
$5.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.99
|
| Rate for Payer: EPIC Health Plan Senior |
$2.99
|
| Rate for Payer: Galaxy Health WC |
$6.36
|
| Rate for Payer: Global Benefits Group Commercial |
$4.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$5.61
|
| Rate for Payer: Networks By Design Commercial |
$4.86
|
| Rate for Payer: Prime Health Services Commercial |
$6.36
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]
|
Facility
|
IP
|
$27.67
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$24.90 |
| Rate for Payer: Adventist Health Commercial |
$5.53
|
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Adventist Health Commercial |
$5.76
|
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Blue Shield of California Commercial |
$21.39
|
| Rate for Payer: Blue Shield of California Commercial |
$18.55
|
| Rate for Payer: Blue Shield of California Commercial |
$37.10
|
| Rate for Payer: Blue Shield of California Commercial |
$22.26
|
| Rate for Payer: Blue Shield of California EPN |
$13.95
|
| Rate for Payer: Blue Shield of California EPN |
$12.10
|
| Rate for Payer: Blue Shield of California EPN |
$14.52
|
| Rate for Payer: Blue Shield of California EPN |
$24.19
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$15.84
|
| Rate for Payer: Cash Price |
$15.22
|
| Rate for Payer: Central Health Plan Commercial |
$38.40
|
| Rate for Payer: Central Health Plan Commercial |
$22.14
|
| Rate for Payer: Central Health Plan Commercial |
$19.20
|
| Rate for Payer: Central Health Plan Commercial |
$23.04
|
| Rate for Payer: Cigna of CA HMO |
$19.37
|
| Rate for Payer: Cigna of CA HMO |
$20.16
|
| Rate for Payer: Cigna of CA HMO |
$33.60
|
| 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 |
$19.37
|
| Rate for Payer: Cigna of CA PPO |
$20.16
|
| Rate for Payer: Cigna of CA PPO |
$33.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.07
|
| Rate for Payer: EPIC Health Plan Senior |
$11.07
|
| Rate for Payer: EPIC Health Plan Senior |
$19.20
|
| Rate for Payer: EPIC Health Plan Senior |
$11.52
|
| Rate for Payer: EPIC Health Plan Senior |
$9.60
|
| Rate for Payer: Galaxy Health WC |
$23.52
|
| Rate for Payer: Galaxy Health WC |
$24.48
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Galaxy Health WC |
$20.40
|
| Rate for Payer: Global Benefits Group Commercial |
$17.28
|
| Rate for Payer: Global Benefits Group Commercial |
$14.40
|
| Rate for Payer: Global Benefits Group Commercial |
$16.60
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$43.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$25.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$21.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.76
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$20.75
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: Networks By Design Commercial |
$24.00
|
| Rate for Payer: Networks By Design Commercial |
$12.00
|
| Rate for Payer: Networks By Design Commercial |
$14.40
|
| Rate for Payer: Networks By Design Commercial |
$13.84
|
| Rate for Payer: Prime Health Services Commercial |
$24.48
|
| Rate for Payer: Prime Health Services Commercial |
$23.52
|
| Rate for Payer: Prime Health Services Commercial |
$20.40
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.38
|
| Rate for Payer: United Healthcare All Other HMO |
$10.11
|
| Rate for Payer: United Healthcare All Other HMO |
$8.77
|
| Rate for Payer: United Healthcare All Other HMO |
$17.53
|
| Rate for Payer: United Healthcare All Other HMO |
$10.52
|
| Rate for Payer: United Healthcare HMO Rider |
$8.58
|
| Rate for Payer: United Healthcare HMO Rider |
$10.29
|
| Rate for Payer: United Healthcare HMO Rider |
$17.16
|
| Rate for Payer: United Healthcare HMO Rider |
$9.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.43
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]
|
Facility
|
OP
|
$27.67
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$24.90 |
| Rate for Payer: Adventist Health Commercial |
$5.53
|
| Rate for Payer: Adventist Health Commercial |
$5.76
|
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$29.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$14.58
|
| Rate for Payer: Aetna of CA HMO/PPO |
$17.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.28
|
| 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 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: Blue Shield of California EPN |
$9.90
|
| Rate for Payer: Blue Shield of California EPN |
$9.90
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$15.22
|
| Rate for Payer: Cash Price |
$15.84
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$15.84
|
| Rate for Payer: Cash Price |
$15.22
|
| Rate for Payer: Central Health Plan Commercial |
$23.04
|
| Rate for Payer: Central Health Plan Commercial |
$22.14
|
| Rate for Payer: Central Health Plan Commercial |
$19.20
|
| Rate for Payer: Central Health Plan Commercial |
$38.40
|
| Rate for Payer: Cigna of CA HMO |
$33.60
|
| Rate for Payer: Cigna of CA HMO |
$16.80
|
| Rate for Payer: Cigna of CA HMO |
$19.37
|
| Rate for Payer: Cigna of CA HMO |
$20.16
|
| Rate for Payer: Cigna of CA PPO |
$16.80
|
| Rate for Payer: Cigna of CA PPO |
$19.37
|
| Rate for Payer: Cigna of CA PPO |
$20.16
|
| Rate for Payer: Cigna of CA PPO |
$33.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$23.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$40.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.52
|
| Rate for Payer: EPIC Health Plan Senior |
$11.52
|
| Rate for Payer: EPIC Health Plan Senior |
$19.20
|
| Rate for Payer: EPIC Health Plan Senior |
$9.60
|
| Rate for Payer: EPIC Health Plan Senior |
$11.07
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Galaxy Health WC |
$23.52
|
| Rate for Payer: Galaxy Health WC |
$20.40
|
| Rate for Payer: Galaxy Health WC |
$24.48
|
| Rate for Payer: Global Benefits Group Commercial |
$14.40
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Global Benefits Group Commercial |
$17.28
|
| Rate for Payer: Global Benefits Group Commercial |
$16.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$21.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$25.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$43.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.51
|
| Rate for Payer: InnovAge PACE Commercial |
$24.00
|
| Rate for Payer: InnovAge PACE Commercial |
$12.00
|
| Rate for Payer: InnovAge PACE Commercial |
$13.84
|
| Rate for Payer: InnovAge PACE Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$33.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$33.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.80
|
| Rate for Payer: Multiplan Commercial |
$20.75
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Networks By Design Commercial |
$24.00
|
| Rate for Payer: Networks By Design Commercial |
$13.84
|
| Rate for Payer: Networks By Design Commercial |
$14.40
|
| 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 |
$23.52
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
| Rate for Payer: Prime Health Services Commercial |
$24.48
|
| Rate for Payer: Riverside University Health System MISP |
$11.07
|
| Rate for Payer: Riverside University Health System MISP |
$9.60
|
| Rate for Payer: Riverside University Health System MISP |
$11.52
|
| Rate for Payer: Riverside University Health System MISP |
$19.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$14.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.81
|
| Rate for Payer: United Healthcare All Other HMO |
$17.53
|
| Rate for Payer: United Healthcare All Other HMO |
$10.52
|
| Rate for Payer: United Healthcare All Other HMO |
$8.77
|
| Rate for Payer: United Healthcare All Other HMO |
$10.11
|
| Rate for Payer: United Healthcare HMO Rider |
$10.29
|
| Rate for Payer: United Healthcare HMO Rider |
$8.58
|
| Rate for Payer: United Healthcare HMO Rider |
$9.89
|
| Rate for Payer: United Healthcare HMO Rider |
$17.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$23.52
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$24.48
|
| Rate for Payer: Vantage Medical Group Senior |
$20.40
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]
|
Facility
|
IP
|
$22.74
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$20.47 |
| Rate for Payer: Adventist Health Commercial |
$4.55
|
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Adventist Health Commercial |
$6.24
|
| Rate for Payer: Adventist Health Commercial |
$4.22
|
| Rate for Payer: Blue Shield of California Commercial |
$17.58
|
| Rate for Payer: Blue Shield of California Commercial |
$16.33
|
| Rate for Payer: Blue Shield of California Commercial |
$64.93
|
| Rate for Payer: Blue Shield of California Commercial |
$24.12
|
| Rate for Payer: Blue Shield of California EPN |
$11.46
|
| Rate for Payer: Blue Shield of California EPN |
$10.64
|
| Rate for Payer: Blue Shield of California EPN |
$15.72
|
| Rate for Payer: Blue Shield of California EPN |
$42.34
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$11.62
|
| Rate for Payer: Cash Price |
$17.16
|
| Rate for Payer: Cash Price |
$12.51
|
| Rate for Payer: Central Health Plan Commercial |
$67.20
|
| Rate for Payer: Central Health Plan Commercial |
$18.19
|
| Rate for Payer: Central Health Plan Commercial |
$16.90
|
| Rate for Payer: Central Health Plan Commercial |
$24.96
|
| Rate for Payer: Cigna of CA HMO |
$15.92
|
| Rate for Payer: Cigna of CA HMO |
$21.84
|
| Rate for Payer: Cigna of CA HMO |
$58.80
|
| Rate for Payer: Cigna of CA HMO |
$14.78
|
| Rate for Payer: Cigna of CA PPO |
$14.78
|
| Rate for Payer: Cigna of CA PPO |
$15.92
|
| Rate for Payer: Cigna of CA PPO |
$21.84
|
| Rate for Payer: Cigna of CA PPO |
$58.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.10
|
| Rate for Payer: EPIC Health Plan Senior |
$9.10
|
| Rate for Payer: EPIC Health Plan Senior |
$33.60
|
| Rate for Payer: EPIC Health Plan Senior |
$12.48
|
| Rate for Payer: EPIC Health Plan Senior |
$8.45
|
| Rate for Payer: Galaxy Health WC |
$19.33
|
| Rate for Payer: Galaxy Health WC |
$26.52
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Galaxy Health WC |
$17.95
|
| Rate for Payer: Global Benefits Group Commercial |
$18.72
|
| Rate for Payer: Global Benefits Group Commercial |
$12.67
|
| Rate for Payer: Global Benefits Group Commercial |
$13.64
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$75.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$20.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$28.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$52.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.24
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$17.05
|
| Rate for Payer: Multiplan Commercial |
$15.84
|
| Rate for Payer: Multiplan Commercial |
$23.40
|
| Rate for Payer: Networks By Design Commercial |
$42.00
|
| Rate for Payer: Networks By Design Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$15.60
|
| Rate for Payer: Networks By Design Commercial |
$11.37
|
| Rate for Payer: Prime Health Services Commercial |
$26.52
|
| Rate for Payer: Prime Health Services Commercial |
$19.33
|
| Rate for Payer: Prime Health Services Commercial |
$17.95
|
| Rate for Payer: Prime Health Services Commercial |
$71.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$31.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.53
|
| Rate for Payer: United Healthcare All Other HMO |
$8.31
|
| Rate for Payer: United Healthcare All Other HMO |
$7.72
|
| Rate for Payer: United Healthcare All Other HMO |
$30.69
|
| Rate for Payer: United Healthcare All Other HMO |
$11.40
|
| Rate for Payer: United Healthcare HMO Rider |
$7.55
|
| Rate for Payer: United Healthcare HMO Rider |
$11.15
|
| Rate for Payer: United Healthcare HMO Rider |
$30.02
|
| Rate for Payer: United Healthcare HMO Rider |
$8.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$27.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.22
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]
|
Facility
|
OP
|
$22.74
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$20.47 |
| Rate for Payer: Adventist Health Commercial |
$4.55
|
| Rate for Payer: Adventist Health Commercial |
$6.24
|
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Adventist Health Commercial |
$4.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$51.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$12.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$18.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$13.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$63.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$23.40
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.28
|
| 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 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: Blue Shield of California EPN |
$9.90
|
| Rate for Payer: Blue Shield of California EPN |
$9.90
|
| Rate for Payer: Cash Price |
$11.62
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$12.51
|
| Rate for Payer: Cash Price |
$17.16
|
| Rate for Payer: Cash Price |
$11.62
|
| Rate for Payer: Cash Price |
$17.16
|
| Rate for Payer: Cash Price |
$12.51
|
| Rate for Payer: Central Health Plan Commercial |
$24.96
|
| Rate for Payer: Central Health Plan Commercial |
$18.19
|
| Rate for Payer: Central Health Plan Commercial |
$16.90
|
| Rate for Payer: Central Health Plan Commercial |
$67.20
|
| Rate for Payer: Cigna of CA HMO |
$58.80
|
| Rate for Payer: Cigna of CA HMO |
$14.78
|
| Rate for Payer: Cigna of CA HMO |
$15.92
|
| Rate for Payer: Cigna of CA HMO |
$21.84
|
| Rate for Payer: Cigna of CA PPO |
$14.78
|
| Rate for Payer: Cigna of CA PPO |
$15.92
|
| Rate for Payer: Cigna of CA PPO |
$21.84
|
| Rate for Payer: Cigna of CA PPO |
$58.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$19.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$71.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$26.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$17.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.48
|
| Rate for Payer: EPIC Health Plan Senior |
$12.48
|
| Rate for Payer: EPIC Health Plan Senior |
$33.60
|
| Rate for Payer: EPIC Health Plan Senior |
$8.45
|
| Rate for Payer: EPIC Health Plan Senior |
$9.10
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Galaxy Health WC |
$19.33
|
| Rate for Payer: Galaxy Health WC |
$17.95
|
| Rate for Payer: Galaxy Health WC |
$26.52
|
| Rate for Payer: Global Benefits Group Commercial |
$12.67
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Global Benefits Group Commercial |
$18.72
|
| Rate for Payer: Global Benefits Group Commercial |
$13.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$20.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$28.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$75.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.51
|
| Rate for Payer: InnovAge PACE Commercial |
$42.00
|
| Rate for Payer: InnovAge PACE Commercial |
$10.56
|
| Rate for Payer: InnovAge PACE Commercial |
$11.37
|
| Rate for Payer: InnovAge PACE Commercial |
$15.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$52.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$58.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$58.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.78
|
| Rate for Payer: Multiplan Commercial |
$17.05
|
| Rate for Payer: Multiplan Commercial |
$15.84
|
| Rate for Payer: Multiplan Commercial |
$23.40
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: Networks By Design Commercial |
$42.00
|
| Rate for Payer: Networks By Design Commercial |
$11.37
|
| Rate for Payer: Networks By Design Commercial |
$15.60
|
| Rate for Payer: Networks By Design Commercial |
$10.56
|
| Rate for Payer: Prime Health Services Commercial |
$17.95
|
| Rate for Payer: Prime Health Services Commercial |
$19.33
|
| Rate for Payer: Prime Health Services Commercial |
$71.40
|
| Rate for Payer: Prime Health Services Commercial |
$26.52
|
| Rate for Payer: Riverside University Health System MISP |
$9.10
|
| Rate for Payer: Riverside University Health System MISP |
$8.45
|
| Rate for Payer: Riverside University Health System MISP |
$12.48
|
| Rate for Payer: Riverside University Health System MISP |
$33.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$50.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.67
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$50.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$31.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.71
|
| Rate for Payer: United Healthcare All Other HMO |
$30.69
|
| Rate for Payer: United Healthcare All Other HMO |
$11.40
|
| Rate for Payer: United Healthcare All Other HMO |
$7.72
|
| Rate for Payer: United Healthcare All Other HMO |
$8.31
|
| Rate for Payer: United Healthcare HMO Rider |
$11.15
|
| Rate for Payer: United Healthcare HMO Rider |
$7.55
|
| Rate for Payer: United Healthcare HMO Rider |
$8.13
|
| Rate for Payer: United Healthcare HMO Rider |
$30.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$27.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.95
|
| Rate for Payer: Vantage Medical Group Senior |
$19.33
|
| Rate for Payer: Vantage Medical Group Senior |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$26.52
|
| Rate for Payer: Vantage Medical Group Senior |
$17.95
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]
|
Facility
|
OP
|
$103.43
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$93.09 |
| Rate for Payer: Adventist Health Commercial |
$20.69
|
| Rate for Payer: Adventist Health Commercial |
$21.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$64.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$62.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$87.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$56.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$79.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$77.57
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.28
|
| 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 |
$56.89
|
| Rate for Payer: Cash Price |
$56.89
|
| Rate for Payer: Cash Price |
$58.08
|
| Rate for Payer: Cash Price |
$58.08
|
| Rate for Payer: Central Health Plan Commercial |
$82.74
|
| Rate for Payer: Central Health Plan Commercial |
$84.48
|
| Rate for Payer: Cigna of CA HMO |
$73.92
|
| Rate for Payer: Cigna of CA HMO |
$72.40
|
| Rate for Payer: Cigna of CA PPO |
$73.92
|
| Rate for Payer: Cigna of CA PPO |
$72.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$87.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$87.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$89.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.37
|
| Rate for Payer: EPIC Health Plan Senior |
$41.37
|
| Rate for Payer: EPIC Health Plan Senior |
$42.24
|
| Rate for Payer: Galaxy Health WC |
$89.76
|
| Rate for Payer: Galaxy Health WC |
$87.92
|
| Rate for Payer: Global Benefits Group Commercial |
$63.36
|
| Rate for Payer: Global Benefits Group Commercial |
$62.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$95.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$93.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.51
|
| Rate for Payer: InnovAge PACE Commercial |
$51.72
|
| Rate for Payer: InnovAge PACE Commercial |
$52.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$65.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$64.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$72.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$73.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$73.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$72.40
|
| Rate for Payer: Multiplan Commercial |
$77.57
|
| Rate for Payer: Multiplan Commercial |
$79.20
|
| Rate for Payer: Networks By Design Commercial |
$52.80
|
| Rate for Payer: Networks By Design Commercial |
$51.72
|
| Rate for Payer: Prime Health Services Commercial |
$89.76
|
| Rate for Payer: Prime Health Services Commercial |
$87.92
|
| Rate for Payer: Riverside University Health System MISP |
$41.37
|
| Rate for Payer: Riverside University Health System MISP |
$42.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$63.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$62.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$62.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$63.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$39.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$38.82
|
| Rate for Payer: United Healthcare All Other HMO |
$37.78
|
| Rate for Payer: United Healthcare All Other HMO |
$38.58
|
| Rate for Payer: United Healthcare HMO Rider |
$36.97
|
| Rate for Payer: United Healthcare HMO Rider |
$37.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$87.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$87.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.76
|
| Rate for Payer: Vantage Medical Group Senior |
$87.92
|
| Rate for Payer: Vantage Medical Group Senior |
$89.76
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]
|
Facility
|
IP
|
$105.60
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.12 |
| Max. Negotiated Rate |
$95.04 |
| Rate for Payer: Adventist Health Commercial |
$21.12
|
| Rate for Payer: Adventist Health Commercial |
$20.69
|
| Rate for Payer: Blue Shield of California Commercial |
$81.63
|
| Rate for Payer: Blue Shield of California Commercial |
$79.95
|
| Rate for Payer: Blue Shield of California EPN |
$52.13
|
| Rate for Payer: Blue Shield of California EPN |
$53.22
|
| Rate for Payer: Cash Price |
$58.08
|
| Rate for Payer: Cash Price |
$56.89
|
| Rate for Payer: Central Health Plan Commercial |
$84.48
|
| Rate for Payer: Central Health Plan Commercial |
$82.74
|
| Rate for Payer: Cigna of CA HMO |
$72.40
|
| Rate for Payer: Cigna of CA HMO |
$73.92
|
| Rate for Payer: Cigna of CA PPO |
$72.40
|
| Rate for Payer: Cigna of CA PPO |
$73.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.24
|
| Rate for Payer: EPIC Health Plan Senior |
$41.37
|
| Rate for Payer: EPIC Health Plan Senior |
$42.24
|
| Rate for Payer: Galaxy Health WC |
$87.92
|
| Rate for Payer: Galaxy Health WC |
$89.76
|
| Rate for Payer: Global Benefits Group Commercial |
$63.36
|
| Rate for Payer: Global Benefits Group Commercial |
$62.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$93.09
|
| Rate for Payer: Health Management Network EPO/PPO |
$95.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$64.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$65.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.69
|
| Rate for Payer: Multiplan Commercial |
$77.57
|
| Rate for Payer: Multiplan Commercial |
$79.20
|
| Rate for Payer: Networks By Design Commercial |
$51.72
|
| Rate for Payer: Networks By Design Commercial |
$52.80
|
| Rate for Payer: Prime Health Services Commercial |
$89.76
|
| Rate for Payer: Prime Health Services Commercial |
$87.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$38.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$39.63
|
| Rate for Payer: United Healthcare All Other HMO |
$38.58
|
| Rate for Payer: United Healthcare All Other HMO |
$37.78
|
| Rate for Payer: United Healthcare HMO Rider |
$36.97
|
| Rate for Payer: United Healthcare HMO Rider |
$37.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34.58
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
|
IP
|
$6.34
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.71 |
| Rate for Payer: Adventist Health Commercial |
$1.27
|
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Adventist Health Commercial |
$2.11
|
| Rate for Payer: Blue Shield of California Commercial |
$4.90
|
| Rate for Payer: Blue Shield of California Commercial |
$9.28
|
| Rate for Payer: Blue Shield of California Commercial |
$8.16
|
| Rate for Payer: Blue Shield of California EPN |
$5.32
|
| Rate for Payer: Blue Shield of California EPN |
$3.20
|
| Rate for Payer: Blue Shield of California EPN |
$6.05
|
| Rate for Payer: Cash Price |
$3.48
|
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Central Health Plan Commercial |
$9.60
|
| Rate for Payer: Central Health Plan Commercial |
$8.45
|
| Rate for Payer: Central Health Plan Commercial |
$5.07
|
| Rate for Payer: Cigna of CA HMO |
$4.44
|
| Rate for Payer: Cigna of CA HMO |
$7.39
|
| Rate for Payer: Cigna of CA HMO |
$8.40
|
| Rate for Payer: Cigna of CA PPO |
$4.44
|
| Rate for Payer: Cigna of CA PPO |
$8.40
|
| Rate for Payer: Cigna of CA PPO |
$7.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.22
|
| Rate for Payer: EPIC Health Plan Senior |
$4.80
|
| Rate for Payer: EPIC Health Plan Senior |
$4.22
|
| Rate for Payer: EPIC Health Plan Senior |
$2.54
|
| Rate for Payer: Galaxy Health WC |
$10.20
|
| Rate for Payer: Galaxy Health WC |
$8.98
|
| Rate for Payer: Galaxy Health WC |
$5.39
|
| Rate for Payer: Global Benefits Group Commercial |
$7.20
|
| Rate for Payer: Global Benefits Group Commercial |
$6.34
|
| Rate for Payer: Global Benefits Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.11
|
| Rate for Payer: Multiplan Commercial |
$4.75
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$7.92
|
| Rate for Payer: Networks By Design Commercial |
$3.17
|
| Rate for Payer: Networks By Design Commercial |
$5.28
|
| Rate for Payer: Networks By Design Commercial |
$6.00
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
| Rate for Payer: Prime Health Services Commercial |
$5.39
|
| Rate for Payer: Prime Health Services Commercial |
$8.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare All Other HMO |
$3.86
|
| Rate for Payer: United Healthcare All Other HMO |
$2.32
|
| Rate for Payer: United Healthcare HMO Rider |
$3.77
|
| Rate for Payer: United Healthcare HMO Rider |
$4.29
|
| Rate for Payer: United Healthcare HMO Rider |
$2.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.46
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$17.19 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Adventist Health Commercial |
$1.27
|
| Rate for Payer: Adventist Health Commercial |
$2.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.28
|
| 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 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: Blue Shield of California EPN |
$9.90
|
| Rate for Payer: Cash Price |
$3.48
|
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$3.48
|
| Rate for Payer: Central Health Plan Commercial |
$5.07
|
| Rate for Payer: Central Health Plan Commercial |
$9.60
|
| Rate for Payer: Central Health Plan Commercial |
$8.45
|
| Rate for Payer: Cigna of CA HMO |
$4.44
|
| Rate for Payer: Cigna of CA HMO |
$8.40
|
| Rate for Payer: Cigna of CA HMO |
$7.39
|
| Rate for Payer: Cigna of CA PPO |
$7.39
|
| Rate for Payer: Cigna of CA PPO |
$4.44
|
| Rate for Payer: Cigna of CA PPO |
$8.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: EPIC Health Plan Senior |
$4.22
|
| Rate for Payer: EPIC Health Plan Senior |
$4.80
|
| Rate for Payer: EPIC Health Plan Senior |
$2.54
|
| Rate for Payer: Galaxy Health WC |
$5.39
|
| Rate for Payer: Galaxy Health WC |
$8.98
|
| Rate for Payer: Galaxy Health WC |
$10.20
|
| Rate for Payer: Global Benefits Group Commercial |
$6.34
|
| Rate for Payer: Global Benefits Group Commercial |
$3.80
|
| Rate for Payer: Global Benefits Group Commercial |
$7.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$9.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.51
|
| Rate for Payer: InnovAge PACE Commercial |
$3.17
|
| Rate for Payer: InnovAge PACE Commercial |
$6.00
|
| Rate for Payer: InnovAge PACE Commercial |
$5.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.44
|
| Rate for Payer: Multiplan Commercial |
$4.75
|
| Rate for Payer: Multiplan Commercial |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Networks By Design Commercial |
$5.28
|
| Rate for Payer: Networks By Design Commercial |
$3.17
|
| Rate for Payer: Networks By Design Commercial |
$6.00
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
| Rate for Payer: Prime Health Services Commercial |
$5.39
|
| Rate for Payer: Prime Health Services Commercial |
$8.98
|
| Rate for Payer: Riverside University Health System MISP |
$2.54
|
| Rate for Payer: Riverside University Health System MISP |
$4.80
|
| Rate for Payer: Riverside University Health System MISP |
$4.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.96
|
| Rate for Payer: United Healthcare All Other HMO |
$3.86
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare All Other HMO |
$2.32
|
| Rate for Payer: United Healthcare HMO Rider |
$4.29
|
| Rate for Payer: United Healthcare HMO Rider |
$3.77
|
| Rate for Payer: United Healthcare HMO Rider |
$2.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.20
|
| Rate for Payer: Vantage Medical Group Senior |
$10.20
|
| Rate for Payer: Vantage Medical Group Senior |
$8.98
|
| Rate for Payer: Vantage Medical Group Senior |
$5.39
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 69315-184-01
|
| 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 |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.72
|
| 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: 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: InnovAge PACE Commercial |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.92
|
| Rate for Payer: Molina Healthcare of CA 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
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.89
|
|
|
Service Code
|
NDC 0054-8496-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$1.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.95
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Central Health Plan Commercial |
$1.51
|
| Rate for Payer: Cigna of CA HMO |
$1.32
|
| Rate for Payer: Cigna of CA PPO |
$1.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: EPIC Health Plan Senior |
$0.76
|
| Rate for Payer: Galaxy Health WC |
$1.61
|
| Rate for Payer: Global Benefits Group Commercial |
$1.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
| Rate for Payer: Networks By Design Commercial |
$1.23
|
| Rate for Payer: Prime Health Services Commercial |
$1.61
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 69315-184-01
|
| 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 |
$1.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.72
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.81
|
| 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
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 0054-8496-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.42
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.11
|
| Rate for Payer: Blue Shield of California Commercial |
$1.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Central Health Plan Commercial |
$1.51
|
| Rate for Payer: Cigna of CA HMO |
$1.32
|
| Rate for Payer: Cigna of CA PPO |
$1.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: EPIC Health Plan Senior |
$0.76
|
| Rate for Payer: Galaxy Health WC |
$1.61
|
| Rate for Payer: Global Benefits Group Commercial |
$1.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.70
|
| Rate for Payer: InnovAge PACE Commercial |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
| Rate for Payer: Networks By Design Commercial |
$1.23
|
| Rate for Payer: Prime Health Services Commercial |
$1.61
|
| Rate for Payer: Riverside University Health System MISP |
$0.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.95
|
| Rate for Payer: United Healthcare All Other HMO |
$0.95
|
| Rate for Payer: United Healthcare HMO Rider |
$0.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.61
|
| Rate for Payer: Vantage Medical Group Senior |
$1.61
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 0054-4496-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Central Health Plan Commercial |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$0.94
|
| Rate for Payer: Cigna of CA PPO |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: Networks By Design Commercial |
$0.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.14
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 69315-184-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Central Health Plan Commercial |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$0.94
|
| Rate for Payer: Cigna of CA PPO |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: Networks By Design Commercial |
$0.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.14
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 0054-4496-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Central Health Plan Commercial |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$0.94
|
| Rate for Payer: Cigna of CA PPO |
$0.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.21
|
| Rate for Payer: InnovAge PACE Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: Networks By Design Commercial |
$0.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.14
|
| Rate for Payer: Riverside University Health System MISP |
$0.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.67
|
| Rate for Payer: United Healthcare All Other HMO |
$0.67
|
| Rate for Payer: United Healthcare HMO Rider |
$0.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 69315-184-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Central Health Plan Commercial |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$0.94
|
| Rate for Payer: Cigna of CA PPO |
$0.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.21
|
| Rate for Payer: InnovAge PACE Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: Networks By Design Commercial |
$0.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.14
|
| Rate for Payer: Riverside University Health System MISP |
$0.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.67
|
| Rate for Payer: United Healthcare All Other HMO |
$0.67
|
| Rate for Payer: United Healthcare HMO Rider |
$0.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT [14135]
|
Facility
|
OP
|
$855.36
|
|
|
Service Code
|
HCPCS J9218
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$769.82 |
| Rate for Payer: Adventist Health Commercial |
$171.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$519.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$727.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$470.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$641.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$108.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.25
|
| Rate for Payer: Blue Shield of California Commercial |
$66.95
|
| Rate for Payer: Blue Shield of California EPN |
$60.86
|
| Rate for Payer: Cash Price |
$470.45
|
| Rate for Payer: Cash Price |
$470.45
|
| Rate for Payer: Central Health Plan Commercial |
$684.29
|
| Rate for Payer: Cigna of CA HMO |
$598.75
|
| Rate for Payer: Cigna of CA PPO |
$598.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$727.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$727.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$727.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$342.14
|
| Rate for Payer: EPIC Health Plan Senior |
$342.14
|
| Rate for Payer: Galaxy Health WC |
$727.06
|
| Rate for Payer: Global Benefits Group Commercial |
$513.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$769.82
|
| Rate for Payer: InnovAge PACE Commercial |
$427.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$570.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$325.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$529.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$171.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$598.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$598.75
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
| Rate for Payer: Networks By Design Commercial |
$427.68
|
| Rate for Payer: Prime Health Services Commercial |
$727.06
|
| Rate for Payer: Riverside University Health System MISP |
$342.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$513.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$513.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$321.02
|
| Rate for Payer: United Healthcare All Other HMO |
$312.46
|
| Rate for Payer: United Healthcare HMO Rider |
$305.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$280.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$727.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$727.06
|
| Rate for Payer: Vantage Medical Group Senior |
$727.06
|
|
