|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
OP
|
$3.20
|
|
|
Service Code
|
NDC 60505-2502-1
|
| Hospital Charge Code |
1712456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.76
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.89
|
| Rate for Payer: BCBS Transplant Transplant |
$1.92
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Central Health Plan Commercial |
$2.56
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.88
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.40
|
| Rate for Payer: IEHP medi-cal |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.92
|
| Rate for Payer: Riverside University Health MISP |
$1.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.60
|
| Rate for Payer: United Healthcare All Other HMO |
$1.60
|
| Rate for Payer: United Healthcare HMO Rider |
$1.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
IP
|
$1.31
|
|
|
Service Code
|
NDC 70710-1157-3
|
| Hospital Charge Code |
1712456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Central Health Plan Commercial |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
IP
|
$3.20
|
|
|
Service Code
|
NDC 60505-2502-1
|
| Hospital Charge Code |
1712456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Blue Shield of California Commercial |
$2.40
|
| Rate for Payer: Blue Shield of California EPN |
$1.71
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Central Health Plan Commercial |
$2.56
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
OP
|
$6.00
|
|
|
Service Code
|
NDC 62332-062-30
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.54
|
| Rate for Payer: BCBS Transplant Transplant |
$3.60
|
| Rate for Payer: Blue Shield of California Commercial |
$3.77
|
| Rate for Payer: Blue Shield of California EPN |
$2.93
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Central Health Plan Commercial |
$4.80
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.50
|
| Rate for Payer: IEHP medi-cal |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: Riverside University Health MISP |
$2.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.00
|
| Rate for Payer: United Healthcare All Other HMO |
$3.00
|
| Rate for Payer: United Healthcare HMO Rider |
$3.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
IP
|
$6.00
|
|
|
Service Code
|
NDC 62332-062-30
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Blue Shield of California Commercial |
$4.50
|
| Rate for Payer: Blue Shield of California EPN |
$3.20
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Central Health Plan Commercial |
$4.80
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
OP
|
$3.32
|
|
|
Service Code
|
NDC 60505-2503-1
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.96
|
| Rate for Payer: BCBS Transplant Transplant |
$1.99
|
| Rate for Payer: Blue Shield of California Commercial |
$2.09
|
| Rate for Payer: Blue Shield of California EPN |
$1.62
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Central Health Plan Commercial |
$2.66
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.99
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.49
|
| Rate for Payer: IEHP medi-cal |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.99
|
| Rate for Payer: Riverside University Health MISP |
$1.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.66
|
| Rate for Payer: United Healthcare All Other HMO |
$1.66
|
| Rate for Payer: United Healthcare HMO Rider |
$1.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Vantage Medical Group Senior |
$2.82
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
OP
|
$0.88
|
|
|
Service Code
|
NDC 23155-044-03
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.52
|
| Rate for Payer: BCBS Transplant Transplant |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Central Health Plan Commercial |
$0.70
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.79
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.66
|
| Rate for Payer: IEHP medi-cal |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.75
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.53
|
| Rate for Payer: Riverside University Health MISP |
$0.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.75
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
IP
|
$0.88
|
|
|
Service Code
|
NDC 23155-044-03
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Central Health Plan Commercial |
$0.70
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.75
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
IP
|
$3.32
|
|
|
Service Code
|
NDC 60505-2503-1
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Blue Shield of California Commercial |
$2.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.77
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Central Health Plan Commercial |
$2.66
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
|
|
Lengthening of tendon, flexor, hand or finger, each tendon
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 26478
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,212.08 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,044.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,079.84
|
| Rate for Payer: Blue Shield of California EPN |
$2,212.08
|
| Rate for Payer: Caremore Medicare Advantage |
$4,044.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,459.68
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,044.21
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,632.50
|
| Rate for Payer: IEHP medi-cal |
$6,672.95
|
| Rate for Payer: IEHP Medicare Advantage |
$4,044.21
|
| Rate for Payer: Innovage PACE Commercial |
$6,066.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,044.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,419.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,419.24
|
| Rate for Payer: Prime Health Services Medicare |
$4,286.86
|
| Rate for Payer: Riverside University Health MISP |
$4,448.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendon
|
Facility
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 25280
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,044.21 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,044.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,567.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,830.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,824.53
|
| Rate for Payer: Blue Shield of California EPN |
$4,183.44
|
| Rate for Payer: Caremore Medicare Advantage |
$4,044.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,459.68
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,044.21
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,632.50
|
| Rate for Payer: IEHP medi-cal |
$6,672.95
|
| Rate for Payer: IEHP Medicare Advantage |
$4,044.21
|
| Rate for Payer: Innovage PACE Commercial |
$6,066.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,044.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,419.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,419.24
|
| Rate for Payer: Prime Health Services Medicare |
$4,286.86
|
| Rate for Payer: Riverside University Health MISP |
$4,448.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,537.00
|
| Rate for Payer: United Healthcare All Other HMO |
$19,907.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,444.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,379.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
IP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-02
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$15.50 |
| Rate for Payer: Blue Shield of California Commercial |
$12.92
|
| Rate for Payer: Blue Shield of California EPN |
$9.20
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: Central Health Plan Commercial |
$13.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.89
|
| Rate for Payer: Galaxy Health WC |
$14.64
|
| Rate for Payer: Global Benefits Group Commercial |
$10.33
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.44
|
| Rate for Payer: Multiplan Commercial |
$12.92
|
| Rate for Payer: Networks By Design Commercial |
$11.19
|
| Rate for Payer: Prime Health Services Commercial |
$14.64
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
OP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-02
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$15.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$10.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.17
|
| Rate for Payer: BCBS Transplant Transplant |
$10.33
|
| Rate for Payer: Blue Shield of California Commercial |
$10.83
|
| Rate for Payer: Blue Shield of California EPN |
$8.42
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: Central Health Plan Commercial |
$13.78
|
| Rate for Payer: Cigna of CA HMO |
$11.02
|
| Rate for Payer: Cigna of CA PPO |
$12.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.89
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.89
|
| Rate for Payer: Galaxy Health WC |
$14.64
|
| Rate for Payer: Global Benefits Group Commercial |
$10.33
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$12.92
|
| Rate for Payer: IEHP medi-cal |
$6.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.44
|
| Rate for Payer: Multiplan Commercial |
$12.92
|
| Rate for Payer: Networks By Design Commercial |
$11.19
|
| Rate for Payer: Prime Health Services Commercial |
$14.64
|
| Rate for Payer: Riverside University Health MISP |
$6.89
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.61
|
| Rate for Payer: United Healthcare All Other HMO |
$8.61
|
| Rate for Payer: United Healthcare HMO Rider |
$8.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.64
|
| Rate for Payer: Vantage Medical Group Senior |
$14.64
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
OP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-01
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$15.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$10.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.17
|
| Rate for Payer: BCBS Transplant Transplant |
$10.33
|
| Rate for Payer: Blue Shield of California Commercial |
$10.83
|
| Rate for Payer: Blue Shield of California EPN |
$8.42
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: Central Health Plan Commercial |
$13.78
|
| Rate for Payer: Cigna of CA HMO |
$11.02
|
| Rate for Payer: Cigna of CA PPO |
$12.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.89
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.89
|
| Rate for Payer: Galaxy Health WC |
$14.64
|
| Rate for Payer: Global Benefits Group Commercial |
$10.33
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$12.92
|
| Rate for Payer: IEHP medi-cal |
$6.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.44
|
| Rate for Payer: Multiplan Commercial |
$12.92
|
| Rate for Payer: Networks By Design Commercial |
$11.19
|
| Rate for Payer: Prime Health Services Commercial |
$14.64
|
| Rate for Payer: Riverside University Health MISP |
$6.89
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.61
|
| Rate for Payer: United Healthcare All Other HMO |
$8.61
|
| Rate for Payer: United Healthcare HMO Rider |
$8.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.64
|
| Rate for Payer: Vantage Medical Group Senior |
$14.64
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
IP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-01
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$15.50 |
| Rate for Payer: Blue Shield of California Commercial |
$12.92
|
| Rate for Payer: Blue Shield of California EPN |
$9.20
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: Central Health Plan Commercial |
$13.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.89
|
| Rate for Payer: Galaxy Health WC |
$14.64
|
| Rate for Payer: Global Benefits Group Commercial |
$10.33
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.44
|
| Rate for Payer: Multiplan Commercial |
$12.92
|
| Rate for Payer: Networks By Design Commercial |
$11.19
|
| Rate for Payer: Prime Health Services Commercial |
$14.64
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
IP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-15
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
OP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-15
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: BCBS Transplant Transplant |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.50
|
| Rate for Payer: IEHP medi-cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: Riverside University Health MISP |
$0.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
IP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-11
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 16729-034-10
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: BCBS Transplant Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.27
|
| Rate for Payer: IEHP medi-cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: Riverside University Health MISP |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 16729-034-10
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
OP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-11
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: BCBS Transplant Transplant |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.50
|
| Rate for Payer: IEHP medi-cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: Riverside University Health MISP |
$0.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
LEUCINE 0.1 GRAM-15 KCAL/4 GRAM ORAL POWDER PACKET [78240]
|
Facility
OP
|
$4.80
|
|
|
Service Code
|
NDC 5060054920
|
| Hospital Charge Code |
ERX78240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.64
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.84
|
| Rate for Payer: BCBS Transplant Transplant |
$2.88
|
| Rate for Payer: Blue Shield of California Commercial |
$3.02
|
| Rate for Payer: Blue Shield of California EPN |
$2.35
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Central Health Plan Commercial |
$3.84
|
| Rate for Payer: Cigna of CA HMO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$3.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.92
|
| Rate for Payer: Galaxy Health WC |
$4.08
|
| Rate for Payer: Global Benefits Group Commercial |
$2.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.60
|
| Rate for Payer: IEHP medi-cal |
$1.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Networks By Design Commercial |
$3.12
|
| Rate for Payer: Prime Health Services Commercial |
$4.08
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.88
|
| Rate for Payer: Riverside University Health MISP |
$1.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.40
|
| Rate for Payer: United Healthcare All Other HMO |
$2.40
|
| Rate for Payer: United Healthcare HMO Rider |
$2.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
|
|
LEUCINE 0.1 GRAM-15 KCAL/4 GRAM ORAL POWDER PACKET [78240]
|
Facility
IP
|
$4.80
|
|
|
Service Code
|
NDC 5060054920
|
| Hospital Charge Code |
ERX78240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Blue Shield of California Commercial |
$3.60
|
| Rate for Payer: Blue Shield of California EPN |
$2.56
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Central Health Plan Commercial |
$3.84
|
| Rate for Payer: Cigna of CA HMO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$3.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Galaxy Health WC |
$4.08
|
| Rate for Payer: Global Benefits Group Commercial |
$2.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Networks By Design Commercial |
$3.12
|
| Rate for Payer: Prime Health Services Commercial |
$4.08
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]
|
Facility
OP
|
$19.20
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.84 |
| Max. Negotiated Rate |
$43.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.56
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$39.77
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$39.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$43.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$43.54
|
| Rate for Payer: BCBS Transplant Transplant |
$11.52
|
| Rate for Payer: BCBS Transplant Transplant |
$14.40
|
| Rate for Payer: Blue Shield of California Commercial |
$10.71
|
| Rate for Payer: Blue Shield of California Commercial |
$10.71
|
| Rate for Payer: Blue Shield of California EPN |
$9.74
|
| Rate for Payer: Blue Shield of California EPN |
$9.74
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Central Health Plan Commercial |
$19.20
|
| Rate for Payer: Central Health Plan Commercial |
$15.36
|
| Rate for Payer: Cigna of CA HMO |
$13.44
|
| Rate for Payer: Cigna of CA HMO |
$16.80
|
| Rate for Payer: Cigna of CA PPO |
$16.80
|
| Rate for Payer: Cigna of CA PPO |
$13.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.68
|
| Rate for Payer: Galaxy Health WC |
$20.40
|
| Rate for Payer: Galaxy Health WC |
$16.32
|
| Rate for Payer: Global Benefits Group Commercial |
$14.40
|
| Rate for Payer: Global Benefits Group Commercial |
$11.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$17.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$21.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$14.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$18.00
|
| Rate for Payer: IEHP medi-cal |
$4.43
|
| Rate for Payer: IEHP medi-cal |
$4.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: Networks By Design Commercial |
$9.60
|
| Rate for Payer: Networks By Design Commercial |
$12.00
|
| Rate for Payer: Prime Health Services Commercial |
$20.40
|
| Rate for Payer: Prime Health Services Commercial |
$16.32
|
| Rate for Payer: Riverside University Health MISP |
$7.68
|
| Rate for Payer: Riverside University Health MISP |
$9.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$14.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$12.00
|
| Rate for Payer: United Healthcare All Other HMO |
$12.00
|
| Rate for Payer: United Healthcare All Other HMO |
$9.60
|
| Rate for Payer: United Healthcare HMO Rider |
$9.60
|
| Rate for Payer: United Healthcare HMO Rider |
$12.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$16.32
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]
|
Facility
IP
|
$19.20
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.84 |
| Max. Negotiated Rate |
$17.28 |
| Rate for Payer: Blue Shield of California Commercial |
$14.40
|
| Rate for Payer: Blue Shield of California Commercial |
$18.00
|
| Rate for Payer: Blue Shield of California EPN |
$10.25
|
| Rate for Payer: Blue Shield of California EPN |
$12.82
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Central Health Plan Commercial |
$15.36
|
| Rate for Payer: Central Health Plan Commercial |
$19.20
|
| Rate for Payer: Cigna of CA HMO |
$16.80
|
| Rate for Payer: Cigna of CA HMO |
$13.44
|
| Rate for Payer: Cigna of CA PPO |
$13.44
|
| Rate for Payer: Cigna of CA PPO |
$16.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.68
|
| Rate for Payer: Galaxy Health WC |
$16.32
|
| Rate for Payer: Galaxy Health WC |
$20.40
|
| Rate for Payer: Global Benefits Group Commercial |
$14.40
|
| Rate for Payer: Global Benefits Group Commercial |
$11.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$21.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$17.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Networks By Design Commercial |
$9.60
|
| Rate for Payer: Networks By Design Commercial |
$12.00
|
| Rate for Payer: Prime Health Services Commercial |
$16.32
|
| Rate for Payer: Prime Health Services Commercial |
$20.40
|
|
