|
LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [15370]
|
Facility
IP
|
$2.84
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
NDG15370A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Blue Shield of California Commercial |
$2.13
|
| Rate for Payer: Blue Shield of California EPN |
$1.52
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Central Health Plan Commercial |
$2.27
|
| Rate for Payer: Cigna of CA HMO |
$1.99
|
| Rate for Payer: Cigna of CA PPO |
$1.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.14
|
| Rate for Payer: Galaxy Health WC |
$2.41
|
| Rate for Payer: Global Benefits Group Commercial |
$1.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
| Rate for Payer: Networks By Design Commercial |
$1.42
|
| Rate for Payer: Prime Health Services Commercial |
$2.41
|
|
|
LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [15370]
|
Facility
OP
|
$2.84
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
NDG15370A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$43.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.56
|
| 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: BCBS Transplant Transplant |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$10.71
|
| Rate for Payer: Blue Shield of California EPN |
$9.74
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Central Health Plan Commercial |
$2.27
|
| Rate for Payer: Cigna of CA HMO |
$1.99
|
| Rate for Payer: Cigna of CA PPO |
$1.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.14
|
| Rate for Payer: Galaxy Health WC |
$2.41
|
| Rate for Payer: Global Benefits Group Commercial |
$1.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.13
|
| Rate for Payer: IEHP medi-cal |
$4.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
| Rate for Payer: Networks By Design Commercial |
$1.42
|
| Rate for Payer: Prime Health Services Commercial |
$2.41
|
| Rate for Payer: Riverside University Health MISP |
$1.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.42
|
| Rate for Payer: United Healthcare All Other HMO |
$1.42
|
| Rate for Payer: United Healthcare HMO Rider |
$1.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.41
|
| Rate for Payer: Vantage Medical Group Senior |
$2.41
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
OP
|
$7.48
|
|
|
Service Code
|
NDC 0054-4497-05
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$6.73 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.42
|
| Rate for Payer: BCBS Transplant Transplant |
$4.49
|
| Rate for Payer: Blue Shield of California Commercial |
$4.70
|
| Rate for Payer: Blue Shield of California EPN |
$3.66
|
| Rate for Payer: Cash Price |
$3.37
|
| 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: EPIC Health Plan Commercial |
$2.99
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$5.61
|
| Rate for Payer: IEHP medi-cal |
$2.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.99
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.49
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$6.36
|
| Rate for Payer: Vantage Medical Group Senior |
$6.36
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
IP
|
$6.65
|
|
|
Service Code
|
NDC 0054-4497-10
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$5.98 |
| Rate for Payer: Blue Shield of California Commercial |
$4.99
|
| Rate for Payer: Blue Shield of California EPN |
$3.55
|
| Rate for Payer: Cash Price |
$2.99
|
| 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: Galaxy Health WC |
$5.65
|
| Rate for Payer: Global Benefits Group Commercial |
$3.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.44
|
| 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
|
$7.48
|
|
|
Service Code
|
NDC 69315-185-12
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$6.73 |
| Rate for Payer: Blue Shield of California Commercial |
$5.61
|
| Rate for Payer: Blue Shield of California EPN |
$3.99
|
| Rate for Payer: Cash Price |
$3.37
|
| 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: 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: 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
OP
|
$7.48
|
|
|
Service Code
|
NDC 69315-185-12
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$6.73 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.42
|
| Rate for Payer: BCBS Transplant Transplant |
$4.49
|
| Rate for Payer: Blue Shield of California Commercial |
$4.70
|
| Rate for Payer: Blue Shield of California EPN |
$3.66
|
| Rate for Payer: Cash Price |
$3.37
|
| 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: EPIC Health Plan Commercial |
$2.99
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$5.61
|
| Rate for Payer: IEHP medi-cal |
$2.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.99
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.49
|
| Rate for Payer: Riverside University Health 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 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 0054-4497-10
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$5.98 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.66
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.93
|
| Rate for Payer: BCBS Transplant Transplant |
$3.99
|
| Rate for Payer: Blue Shield of California Commercial |
$4.18
|
| Rate for Payer: Blue Shield of California EPN |
$3.25
|
| Rate for Payer: Cash Price |
$2.99
|
| 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: EPIC Health Plan Commercial |
$2.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$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 |
$5.98
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.99
|
| Rate for Payer: IEHP medi-cal |
$2.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.44
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.99
|
| Rate for Payer: Riverside University Health 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 |
$3.32
|
| Rate for Payer: United Healthcare All Other HMO |
$3.32
|
| Rate for Payer: United Healthcare HMO Rider |
$3.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.32
|
| 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
|
$6.65
|
|
|
Service Code
|
NDC 69315-185-24
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$5.98 |
| Rate for Payer: Blue Shield of California Commercial |
$4.99
|
| Rate for Payer: Blue Shield of California EPN |
$3.55
|
| Rate for Payer: Cash Price |
$2.99
|
| 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: Galaxy Health WC |
$5.65
|
| Rate for Payer: Global Benefits Group Commercial |
$3.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.44
|
| 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
|
$6.65
|
|
|
Service Code
|
NDC 69315-185-24
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$5.98 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.66
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.93
|
| Rate for Payer: BCBS Transplant Transplant |
$3.99
|
| Rate for Payer: Blue Shield of California Commercial |
$4.18
|
| Rate for Payer: Blue Shield of California EPN |
$3.25
|
| Rate for Payer: Cash Price |
$2.99
|
| 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: EPIC Health Plan Commercial |
$2.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$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 |
$5.98
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.99
|
| Rate for Payer: IEHP medi-cal |
$2.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.44
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.99
|
| Rate for Payer: Riverside University Health 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 |
$3.32
|
| Rate for Payer: United Healthcare All Other HMO |
$3.32
|
| Rate for Payer: United Healthcare HMO Rider |
$3.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.32
|
| 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
|
$7.48
|
|
|
Service Code
|
NDC 0054-4497-05
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$6.73 |
| Rate for Payer: Blue Shield of California Commercial |
$5.61
|
| Rate for Payer: Blue Shield of California EPN |
$3.99
|
| Rate for Payer: Cash Price |
$3.37
|
| 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: 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: 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
|
CPT J0640
|
| Hospital Charge Code |
ERX15426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$24.90 |
| Rate for Payer: Blue Shield of California Commercial |
$20.75
|
| Rate for Payer: Blue Shield of California Commercial |
$36.00
|
| Rate for Payer: Blue Shield of California Commercial |
$21.60
|
| Rate for Payer: Blue Shield of California EPN |
$25.63
|
| Rate for Payer: Blue Shield of California EPN |
$14.78
|
| Rate for Payer: Blue Shield of California EPN |
$15.38
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cash Price |
$12.96
|
| 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 |
$23.04
|
| Rate for Payer: Cigna of CA HMO |
$20.16
|
| Rate for Payer: Cigna of CA HMO |
$19.37
|
| Rate for Payer: Cigna of CA HMO |
$33.60
|
| 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 |
$19.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.20
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Galaxy Health WC |
$23.52
|
| Rate for Payer: Galaxy Health WC |
$24.48
|
| Rate for Payer: Global Benefits Group Commercial |
$16.60
|
| Rate for Payer: Global Benefits Group Commercial |
$17.28
|
| 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 |
$25.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.90
|
| 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 Commercial/Self Funded |
$32.02
|
| 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 |
$5.76
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: Multiplan Commercial |
$20.75
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Networks By Design Commercial |
$24.00
|
| 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 |
$23.52
|
| Rate for Payer: Prime Health Services Commercial |
$24.48
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]
|
Facility
OP
|
$28.80
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
ERX15426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.43 |
| 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: Aetna of CA HMO/PPO |
$27.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$24.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$23.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$26.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.84
|
| 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 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: Anthem Blue Cross of CA HMO/PPO |
$43.54
|
| Rate for Payer: BCBS Transplant Transplant |
$17.28
|
| Rate for Payer: BCBS Transplant Transplant |
$28.80
|
| Rate for Payer: BCBS Transplant Transplant |
$16.60
|
| 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 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: Blue Shield of California EPN |
$9.74
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Central Health Plan Commercial |
$22.14
|
| Rate for Payer: Central Health Plan Commercial |
$23.04
|
| Rate for Payer: Central Health Plan Commercial |
$38.40
|
| 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 PPO |
$33.60
|
| Rate for Payer: Cigna of CA PPO |
$20.16
|
| Rate for Payer: Cigna of CA PPO |
$19.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.52
|
| Rate for Payer: Galaxy Health WC |
$24.48
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Galaxy Health WC |
$23.52
|
| Rate for Payer: Global Benefits Group Commercial |
$16.60
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Global Benefits Group Commercial |
$17.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$43.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$25.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.90
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$20.75
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$21.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$36.00
|
| Rate for Payer: IEHP medi-cal |
$4.43
|
| 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 |
$19.21
|
| 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: LLUH Dept of Risk Management WC |
$5.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.60
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: Multiplan Commercial |
$20.75
|
| Rate for Payer: Networks By Design Commercial |
$24.00
|
| 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 |
$40.80
|
| Rate for Payer: Prime Health Services Commercial |
$23.52
|
| Rate for Payer: Prime Health Services Commercial |
$24.48
|
| Rate for Payer: Riverside University Health MISP |
$11.07
|
| Rate for Payer: Riverside University Health MISP |
$19.20
|
| Rate for Payer: Riverside University Health MISP |
$11.52
|
| 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 |
$16.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.40
|
| Rate for Payer: United Healthcare All Other HMO |
$14.40
|
| Rate for Payer: United Healthcare All Other HMO |
$24.00
|
| Rate for Payer: United Healthcare All Other HMO |
$13.84
|
| Rate for Payer: United Healthcare HMO Rider |
$24.00
|
| Rate for Payer: United Healthcare HMO Rider |
$14.40
|
| Rate for Payer: United Healthcare HMO Rider |
$13.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.00
|
| 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 Senior |
$24.48
|
| Rate for Payer: Vantage Medical Group Senior |
$23.52
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]
|
Facility
OP
|
$22.74
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.43 |
| 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: 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 |
$19.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$46.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$46.20
|
| 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 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: 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 |
$18.72
|
| Rate for Payer: BCBS Transplant Transplant |
$50.40
|
| Rate for Payer: BCBS Transplant Transplant |
$12.67
|
| Rate for Payer: BCBS Transplant Transplant |
$13.64
|
| 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 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: Blue Shield of California EPN |
$9.74
|
| Rate for Payer: Blue Shield of California EPN |
$9.74
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Central Health Plan Commercial |
$24.96
|
| Rate for Payer: Central Health Plan Commercial |
$16.90
|
| Rate for Payer: Central Health Plan Commercial |
$18.19
|
| 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 |
$21.84
|
| Rate for Payer: Cigna of CA HMO |
$15.92
|
| Rate for Payer: Cigna of CA PPO |
$14.78
|
| Rate for Payer: Cigna of CA PPO |
$21.84
|
| Rate for Payer: Cigna of CA PPO |
$58.80
|
| Rate for Payer: Cigna of CA PPO |
$15.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.45
|
| Rate for Payer: EPIC Health Plan Transplant |
$33.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.10
|
| Rate for Payer: Galaxy Health WC |
$17.95
|
| 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: Global Benefits Group Commercial |
$18.72
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Global Benefits Group Commercial |
$12.67
|
| Rate for Payer: Global Benefits Group Commercial |
$13.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$28.08
|
| 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 |
$75.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$63.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$15.84
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$17.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$23.40
|
| Rate for Payer: IEHP medi-cal |
$4.43
|
| Rate for Payer: IEHP medi-cal |
$4.43
|
| 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 |
$20.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.17
|
| 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: LLUH Dept of Risk Management WC |
$4.55
|
| 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 |
$4.22
|
| Rate for Payer: Multiplan Commercial |
$17.06
|
| 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 |
$11.37
|
| Rate for Payer: Networks By Design Commercial |
$15.60
|
| Rate for Payer: Networks By Design Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$42.00
|
| Rate for Payer: Prime Health Services Commercial |
$26.52
|
| 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: Riverside University Health MISP |
$9.10
|
| Rate for Payer: Riverside University Health MISP |
$12.48
|
| Rate for Payer: Riverside University Health MISP |
$8.45
|
| Rate for Payer: Riverside University Health MISP |
$33.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$50.40
|
| 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: TriValley Medical Group Commercial/Senior |
$12.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.60
|
| Rate for Payer: United Healthcare All Other HMO |
$10.56
|
| Rate for Payer: United Healthcare All Other HMO |
$11.37
|
| Rate for Payer: United Healthcare All Other HMO |
$42.00
|
| Rate for Payer: United Healthcare All Other HMO |
$15.60
|
| Rate for Payer: United Healthcare HMO Rider |
$10.56
|
| Rate for Payer: United Healthcare HMO Rider |
$42.00
|
| Rate for Payer: United Healthcare HMO Rider |
$11.37
|
| Rate for Payer: United Healthcare HMO Rider |
$15.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$42.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$26.52
|
| Rate for Payer: Vantage Medical Group Senior |
$17.95
|
| Rate for Payer: Vantage Medical Group Senior |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$19.33
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]
|
Facility
IP
|
$21.12
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.22 |
| Max. Negotiated Rate |
$19.01 |
| Rate for Payer: Blue Shield of California Commercial |
$15.84
|
| Rate for Payer: Blue Shield of California Commercial |
$17.06
|
| Rate for Payer: Blue Shield of California Commercial |
$23.40
|
| Rate for Payer: Blue Shield of California Commercial |
$63.00
|
| Rate for Payer: Blue Shield of California EPN |
$11.28
|
| Rate for Payer: Blue Shield of California EPN |
$12.14
|
| Rate for Payer: Blue Shield of California EPN |
$44.86
|
| Rate for Payer: Blue Shield of California EPN |
$16.66
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Central Health Plan Commercial |
$67.20
|
| Rate for Payer: Central Health Plan Commercial |
$16.90
|
| Rate for Payer: Central Health Plan Commercial |
$18.19
|
| Rate for Payer: Central Health Plan Commercial |
$24.96
|
| 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 |
$15.92
|
| Rate for Payer: Cigna of CA HMO |
$14.78
|
| Rate for Payer: Cigna of CA PPO |
$21.84
|
| Rate for Payer: Cigna of CA PPO |
$15.92
|
| Rate for Payer: Cigna of CA PPO |
$14.78
|
| Rate for Payer: Cigna of CA PPO |
$58.80
|
| 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 Commercial |
$8.45
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$33.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.45
|
| Rate for Payer: Galaxy Health WC |
$19.33
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Galaxy Health WC |
$17.95
|
| Rate for Payer: Galaxy Health WC |
$26.52
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Global Benefits Group Commercial |
$12.67
|
| 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: 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 |
$56.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.24
|
| 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: Multiplan Commercial |
$23.40
|
| Rate for Payer: Multiplan Commercial |
$17.06
|
| Rate for Payer: Multiplan Commercial |
$15.84
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: Networks By Design Commercial |
$11.37
|
| 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 |
$42.00
|
| Rate for Payer: Prime Health Services Commercial |
$26.52
|
| Rate for Payer: Prime Health Services Commercial |
$71.40
|
| Rate for Payer: Prime Health Services Commercial |
$17.95
|
| Rate for Payer: Prime Health Services Commercial |
$19.33
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]
|
Facility
OP
|
$120.00
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
ERX23617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$108.00 |
| 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 |
$87.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$56.89
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$56.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$66.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$39.77
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$39.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$43.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$43.54
|
| Rate for Payer: BCBS Transplant Transplant |
$72.00
|
| Rate for Payer: BCBS Transplant Transplant |
$62.06
|
| 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 |
$54.00
|
| Rate for Payer: Cash Price |
$46.54
|
| Rate for Payer: Cash Price |
$46.54
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Central Health Plan Commercial |
$96.00
|
| Rate for Payer: Central Health Plan Commercial |
$82.74
|
| Rate for Payer: Cigna of CA HMO |
$84.00
|
| Rate for Payer: Cigna of CA HMO |
$72.40
|
| Rate for Payer: Cigna of CA PPO |
$72.40
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.37
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Galaxy Health WC |
$87.92
|
| Rate for Payer: Global Benefits Group Commercial |
$62.06
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$108.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$93.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$77.57
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$90.00
|
| 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 |
$80.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.69
|
| Rate for Payer: Multiplan Commercial |
$77.57
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Networks By Design Commercial |
$51.72
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
| Rate for Payer: Prime Health Services Commercial |
$87.92
|
| Rate for Payer: Riverside University Health MISP |
$48.00
|
| Rate for Payer: Riverside University Health MISP |
$41.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$62.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$72.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$72.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$62.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$51.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.00
|
| Rate for Payer: United Healthcare All Other HMO |
$60.00
|
| Rate for Payer: United Healthcare All Other HMO |
$51.72
|
| Rate for Payer: United Healthcare HMO Rider |
$51.72
|
| Rate for Payer: United Healthcare HMO Rider |
$60.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$51.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$87.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.00
|
| Rate for Payer: Vantage Medical Group Senior |
$87.92
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]
|
Facility
IP
|
$103.43
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
ERX23617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.69 |
| Max. Negotiated Rate |
$93.09 |
| Rate for Payer: Blue Shield of California Commercial |
$77.57
|
| Rate for Payer: Blue Shield of California Commercial |
$90.00
|
| Rate for Payer: Blue Shield of California EPN |
$64.08
|
| Rate for Payer: Blue Shield of California EPN |
$55.23
|
| Rate for Payer: Cash Price |
$46.54
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Central Health Plan Commercial |
$96.00
|
| 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 |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$72.40
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.00
|
| Rate for Payer: Galaxy Health WC |
$87.92
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Global Benefits Group Commercial |
$62.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$108.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$93.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.69
|
| Rate for Payer: Multiplan Commercial |
$77.57
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Networks By Design Commercial |
$51.72
|
| Rate for Payer: Prime Health Services Commercial |
$87.92
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
OP
|
$6.34
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.27 |
| 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 |
$10.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.60
|
| 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 |
$7.20
|
| Rate for Payer: BCBS Transplant Transplant |
$3.80
|
| 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 |
$2.85
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Central Health Plan Commercial |
$5.07
|
| Rate for Payer: Central Health Plan Commercial |
$9.60
|
| Rate for Payer: Cigna of CA HMO |
$4.44
|
| 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: Dignity Health Commercial/Exchange |
$5.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.80
|
| Rate for Payer: Galaxy Health WC |
$10.20
|
| Rate for Payer: Galaxy Health WC |
$5.39
|
| 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 |
$10.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$9.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.76
|
| 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 |
$8.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: Multiplan Commercial |
$4.76
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| 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: Riverside University Health MISP |
$2.54
|
| Rate for Payer: Riverside University Health MISP |
$4.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.00
|
| Rate for Payer: United Healthcare All Other HMO |
$6.00
|
| Rate for Payer: United Healthcare All Other HMO |
$3.17
|
| Rate for Payer: United Healthcare HMO Rider |
$6.00
|
| Rate for Payer: United Healthcare HMO Rider |
$3.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.00
|
| 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 |
$5.39
|
| Rate for Payer: Vantage Medical Group Senior |
$10.20
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
IP
|
$6.34
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.71 |
| Rate for Payer: Blue Shield of California Commercial |
$4.76
|
| Rate for Payer: Blue Shield of California Commercial |
$9.00
|
| Rate for Payer: Blue Shield of California EPN |
$6.41
|
| Rate for Payer: Blue Shield of California EPN |
$3.39
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Central Health Plan Commercial |
$9.60
|
| Rate for Payer: Central Health Plan Commercial |
$5.07
|
| Rate for Payer: Cigna of CA HMO |
$8.40
|
| Rate for Payer: Cigna of CA HMO |
$4.44
|
| Rate for Payer: Cigna of CA PPO |
$8.40
|
| Rate for Payer: Cigna of CA PPO |
$4.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.54
|
| Rate for Payer: Galaxy Health WC |
$10.20
|
| Rate for Payer: Galaxy Health WC |
$5.39
|
| Rate for Payer: Global Benefits Group Commercial |
$7.20
|
| 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: Kaiser Permanente of CA Commercial/Self Funded |
$4.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.00
|
| 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: Multiplan Commercial |
$4.76
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Networks By Design Commercial |
$6.00
|
| Rate for Payer: Networks By Design Commercial |
$3.17
|
| Rate for Payer: Prime Health Services Commercial |
$5.39
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
IP
|
$1.34
|
|
|
Service Code
|
NDC 0054-4496-13
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.60
|
| 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: 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: 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 |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.74
|
| 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: BCBS Transplant Transplant |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.84
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.60
|
| 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: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$1.00
|
| Rate for Payer: IEHP medi-cal |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.80
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
IP
|
$1.34
|
|
|
Service Code
|
NDC 69315-184-03
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.60
|
| 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: 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: 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 69315-184-03
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.74
|
| 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: BCBS Transplant Transplant |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.84
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.60
|
| 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: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$1.00
|
| Rate for Payer: IEHP medi-cal |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.80
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
OP
|
$1.89
|
|
|
Service Code
|
NDC 0054-8496-19
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.12
|
| Rate for Payer: BCBS Transplant Transplant |
$1.13
|
| Rate for Payer: Blue Shield of California Commercial |
$1.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Cash Price |
$0.85
|
| 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: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$1.42
|
| Rate for Payer: IEHP medi-cal |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.26
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.13
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$1.61
|
| Rate for Payer: Vantage Medical Group Senior |
$1.61
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
IP
|
$1.89
|
|
|
Service Code
|
NDC 0054-8496-19
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.01
|
| Rate for Payer: Cash Price |
$0.85
|
| 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: 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: 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
|
|
|
LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]
|
Facility
IP
|
$5,881.22
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
ERX21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,176.24 |
| Max. Negotiated Rate |
$5,293.10 |
| Rate for Payer: Blue Shield of California Commercial |
$4,410.92
|
| Rate for Payer: Blue Shield of California EPN |
$3,140.57
|
| Rate for Payer: Cash Price |
$2,646.55
|
| Rate for Payer: Central Health Plan Commercial |
$4,704.98
|
| Rate for Payer: Cigna of CA HMO |
$4,116.85
|
| Rate for Payer: Cigna of CA PPO |
$4,116.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,352.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,352.49
|
| Rate for Payer: Galaxy Health WC |
$4,999.04
|
| Rate for Payer: Global Benefits Group Commercial |
$3,528.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$5,293.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,922.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,176.24
|
| Rate for Payer: Multiplan Commercial |
$4,410.92
|
| Rate for Payer: Networks By Design Commercial |
$2,940.61
|
| Rate for Payer: Prime Health Services Commercial |
$4,999.04
|
|
