|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 6846271408
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$2.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Central Health Plan Commercial |
$2.40
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
|
|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
|
IP
|
$7.37
|
|
|
Service Code
|
NDC 0054042623
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$6.63 |
| Rate for Payer: Adventist Health Commercial |
$1.47
|
| Rate for Payer: Blue Shield of California Commercial |
$5.91
|
| Rate for Payer: Blue Shield of California EPN |
$3.71
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Central Health Plan Commercial |
$5.90
|
| Rate for Payer: Cigna of CA HMO |
$5.16
|
| Rate for Payer: Cigna of CA PPO |
$5.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.95
|
| Rate for Payer: EPIC Health Plan Senior |
$2.95
|
| Rate for Payer: Galaxy Health WC |
$6.26
|
| Rate for Payer: Global Benefits Group Commercial |
$4.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.47
|
| Rate for Payer: Multiplan Commercial |
$5.53
|
| Rate for Payer: Networks By Design Commercial |
$4.79
|
| Rate for Payer: Prime Health Services Commercial |
$6.26
|
|
|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 3172259912
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.09
|
| Rate for Payer: Blue Shield of California Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.44
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Central Health Plan Commercial |
$2.88
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Senior |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.52
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Networks By Design Commercial |
$2.34
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
| Rate for Payer: Riverside University Health System MISP |
$1.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO |
$1.80
|
| Rate for Payer: United Healthcare HMO Rider |
$1.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
NDC 4257139212
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Central Health Plan Commercial |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Senior |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
|
|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
NDC 4257139212
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.05
|
| Rate for Payer: Blue Shield of California Commercial |
$1.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Central Health Plan Commercial |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.53
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Senior |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
| Rate for Payer: Riverside University Health System MISP |
$0.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare HMO Rider |
$0.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 3172259912
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$2.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.81
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Central Health Plan Commercial |
$2.88
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Senior |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Networks By Design Commercial |
$2.34
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
|
|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 6846271408
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1.90
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Central Health Plan Commercial |
$2.40
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.55
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
| Rate for Payer: Riverside University Health System MISP |
$1.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.50
|
| Rate for Payer: United Healthcare All Other HMO |
$1.50
|
| Rate for Payer: United Healthcare HMO Rider |
$1.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
|
OP
|
$7.37
|
|
|
Service Code
|
NDC 0054042623
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$6.63 |
| Rate for Payer: Adventist Health Commercial |
$1.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.53
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.29
|
| Rate for Payer: Blue Shield of California Commercial |
$4.67
|
| Rate for Payer: Blue Shield of California EPN |
$2.94
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Central Health Plan Commercial |
$5.90
|
| Rate for Payer: Cigna of CA HMO |
$5.16
|
| Rate for Payer: Cigna of CA PPO |
$5.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.95
|
| Rate for Payer: EPIC Health Plan Senior |
$2.95
|
| Rate for Payer: Galaxy Health WC |
$6.26
|
| Rate for Payer: Global Benefits Group Commercial |
$4.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.16
|
| Rate for Payer: Multiplan Commercial |
$5.53
|
| Rate for Payer: Networks By Design Commercial |
$4.79
|
| Rate for Payer: Prime Health Services Commercial |
$6.26
|
| Rate for Payer: Riverside University Health System MISP |
$2.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.69
|
| Rate for Payer: United Healthcare All Other HMO |
$3.69
|
| Rate for Payer: United Healthcare HMO Rider |
$3.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.26
|
| Rate for Payer: Vantage Medical Group Senior |
$6.26
|
|
|
RUFINAMIDE 40 MG/ML ORAL SUSPENSION [108804]
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
NDC 6285658446
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Adventist Health Commercial |
$0.92
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.67
|
| Rate for Payer: Blue Shield of California Commercial |
$2.91
|
| Rate for Payer: Blue Shield of California EPN |
$1.83
|
| Rate for Payer: Cash Price |
$2.07
|
| Rate for Payer: Central Health Plan Commercial |
$3.67
|
| Rate for Payer: Cigna of CA HMO |
$3.21
|
| Rate for Payer: Cigna of CA PPO |
$3.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.90
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.84
|
| Rate for Payer: EPIC Health Plan Senior |
$1.84
|
| Rate for Payer: Galaxy Health WC |
$3.90
|
| Rate for Payer: Global Benefits Group Commercial |
$2.75
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$3.44
|
| Rate for Payer: Networks By Design Commercial |
$2.98
|
| Rate for Payer: Prime Health Services Commercial |
$3.90
|
| Rate for Payer: Riverside University Health System MISP |
$1.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.75
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.29
|
| Rate for Payer: United Healthcare All Other HMO |
$2.29
|
| Rate for Payer: United Healthcare HMO Rider |
$2.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.90
|
| Rate for Payer: Vantage Medical Group Senior |
$3.90
|
|
|
RUFINAMIDE 40 MG/ML ORAL SUSPENSION [108804]
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
NDC 6285658446
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Adventist Health Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$3.68
|
| Rate for Payer: Blue Shield of California EPN |
$2.31
|
| Rate for Payer: Cash Price |
$2.07
|
| Rate for Payer: Central Health Plan Commercial |
$3.67
|
| Rate for Payer: Cigna of CA HMO |
$3.21
|
| Rate for Payer: Cigna of CA PPO |
$3.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.84
|
| Rate for Payer: EPIC Health Plan Senior |
$1.84
|
| Rate for Payer: Galaxy Health WC |
$3.90
|
| Rate for Payer: Global Benefits Group Commercial |
$2.75
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.44
|
| Rate for Payer: Networks By Design Commercial |
$2.98
|
| Rate for Payer: Prime Health Services Commercial |
$3.90
|
|
|
RUXOLITINIB 10 MG TABLET [153887]
|
Facility
|
IP
|
$363.80
|
|
|
Service Code
|
NDC 5088101060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$72.76 |
| Max. Negotiated Rate |
$327.42 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Blue Shield of California Commercial |
$291.77
|
| Rate for Payer: Blue Shield of California EPN |
$183.36
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Central Health Plan Commercial |
$291.04
|
| Rate for Payer: Cigna of CA HMO |
$254.66
|
| Rate for Payer: Cigna of CA PPO |
$254.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$254.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.52
|
| Rate for Payer: EPIC Health Plan Senior |
$145.52
|
| Rate for Payer: Galaxy Health WC |
$309.23
|
| Rate for Payer: Global Benefits Group Commercial |
$218.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$327.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$231.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$214.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.76
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: Networks By Design Commercial |
$236.47
|
| Rate for Payer: Prime Health Services Commercial |
$309.23
|
|
|
RUXOLITINIB 10 MG TABLET [153887]
|
Facility
|
OP
|
$363.80
|
|
|
Service Code
|
NDC 5088101060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$72.76 |
| Max. Negotiated Rate |
$327.42 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$220.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$200.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$272.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$176.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$211.62
|
| Rate for Payer: Blue Shield of California Commercial |
$230.65
|
| Rate for Payer: Blue Shield of California EPN |
$145.16
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Central Health Plan Commercial |
$291.04
|
| Rate for Payer: Cigna of CA HMO |
$254.66
|
| Rate for Payer: Cigna of CA PPO |
$254.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$309.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$309.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$309.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$254.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.52
|
| Rate for Payer: EPIC Health Plan Senior |
$145.52
|
| Rate for Payer: Galaxy Health WC |
$309.23
|
| Rate for Payer: Global Benefits Group Commercial |
$218.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$327.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$231.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$132.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$214.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$254.66
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: Networks By Design Commercial |
$236.47
|
| Rate for Payer: Prime Health Services Commercial |
$309.23
|
| Rate for Payer: Riverside University Health System MISP |
$145.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$218.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$218.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$181.90
|
| Rate for Payer: United Healthcare All Other HMO |
$181.90
|
| Rate for Payer: United Healthcare HMO Rider |
$181.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$181.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$309.23
|
| Rate for Payer: Vantage Medical Group Senior |
$309.23
|
|
|
RUXOLITINIB 15 MG TABLET [153888]
|
Facility
|
IP
|
$363.80
|
|
|
Service Code
|
NDC 5088101560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$72.76 |
| Max. Negotiated Rate |
$327.42 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Blue Shield of California Commercial |
$291.77
|
| Rate for Payer: Blue Shield of California EPN |
$183.36
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Central Health Plan Commercial |
$291.04
|
| Rate for Payer: Cigna of CA HMO |
$254.66
|
| Rate for Payer: Cigna of CA PPO |
$254.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$254.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.52
|
| Rate for Payer: EPIC Health Plan Senior |
$145.52
|
| Rate for Payer: Galaxy Health WC |
$309.23
|
| Rate for Payer: Global Benefits Group Commercial |
$218.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$327.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$231.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$214.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.76
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: Networks By Design Commercial |
$236.47
|
| Rate for Payer: Prime Health Services Commercial |
$309.23
|
|
|
RUXOLITINIB 15 MG TABLET [153888]
|
Facility
|
OP
|
$363.80
|
|
|
Service Code
|
NDC 5088101560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$72.76 |
| Max. Negotiated Rate |
$327.42 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$220.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$200.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$272.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$176.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$211.62
|
| Rate for Payer: Blue Shield of California Commercial |
$230.65
|
| Rate for Payer: Blue Shield of California EPN |
$145.16
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Central Health Plan Commercial |
$291.04
|
| Rate for Payer: Cigna of CA HMO |
$254.66
|
| Rate for Payer: Cigna of CA PPO |
$254.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$309.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$309.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$309.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$254.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.52
|
| Rate for Payer: EPIC Health Plan Senior |
$145.52
|
| Rate for Payer: Galaxy Health WC |
$309.23
|
| Rate for Payer: Global Benefits Group Commercial |
$218.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$327.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$231.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$132.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$214.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$254.66
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: Networks By Design Commercial |
$236.47
|
| Rate for Payer: Prime Health Services Commercial |
$309.23
|
| Rate for Payer: Riverside University Health System MISP |
$145.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$218.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$218.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$181.90
|
| Rate for Payer: United Healthcare All Other HMO |
$181.90
|
| Rate for Payer: United Healthcare HMO Rider |
$181.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$181.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$309.23
|
| Rate for Payer: Vantage Medical Group Senior |
$309.23
|
|
|
RUXOLITINIB 20 MG TABLET [153889]
|
Facility
|
IP
|
$363.80
|
|
|
Service Code
|
NDC 5088102060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$72.76 |
| Max. Negotiated Rate |
$327.42 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Blue Shield of California Commercial |
$291.77
|
| Rate for Payer: Blue Shield of California EPN |
$183.36
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Central Health Plan Commercial |
$291.04
|
| Rate for Payer: Cigna of CA HMO |
$254.66
|
| Rate for Payer: Cigna of CA PPO |
$254.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$254.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.52
|
| Rate for Payer: EPIC Health Plan Senior |
$145.52
|
| Rate for Payer: Galaxy Health WC |
$309.23
|
| Rate for Payer: Global Benefits Group Commercial |
$218.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$327.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$231.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$214.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.76
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: Networks By Design Commercial |
$236.47
|
| Rate for Payer: Prime Health Services Commercial |
$309.23
|
|
|
RUXOLITINIB 20 MG TABLET [153889]
|
Facility
|
OP
|
$363.80
|
|
|
Service Code
|
NDC 5088102060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$72.76 |
| Max. Negotiated Rate |
$327.42 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$220.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$200.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$272.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$176.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$211.62
|
| Rate for Payer: Blue Shield of California Commercial |
$230.65
|
| Rate for Payer: Blue Shield of California EPN |
$145.16
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Central Health Plan Commercial |
$291.04
|
| Rate for Payer: Cigna of CA HMO |
$254.66
|
| Rate for Payer: Cigna of CA PPO |
$254.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$309.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$309.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$309.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$254.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.52
|
| Rate for Payer: EPIC Health Plan Senior |
$145.52
|
| Rate for Payer: Galaxy Health WC |
$309.23
|
| Rate for Payer: Global Benefits Group Commercial |
$218.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$327.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$231.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$132.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$214.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$254.66
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: Networks By Design Commercial |
$236.47
|
| Rate for Payer: Prime Health Services Commercial |
$309.23
|
| Rate for Payer: Riverside University Health System MISP |
$145.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$218.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$218.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$181.90
|
| Rate for Payer: United Healthcare All Other HMO |
$181.90
|
| Rate for Payer: United Healthcare HMO Rider |
$181.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$181.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$309.23
|
| Rate for Payer: Vantage Medical Group Senior |
$309.23
|
|
|
RUXOLITINIB 25 MG TABLET [153890]
|
Facility
|
IP
|
$363.80
|
|
|
Service Code
|
NDC 5088102560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$72.76 |
| Max. Negotiated Rate |
$327.42 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Blue Shield of California Commercial |
$291.77
|
| Rate for Payer: Blue Shield of California EPN |
$183.36
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Central Health Plan Commercial |
$291.04
|
| Rate for Payer: Cigna of CA HMO |
$254.66
|
| Rate for Payer: Cigna of CA PPO |
$254.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$254.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.52
|
| Rate for Payer: EPIC Health Plan Senior |
$145.52
|
| Rate for Payer: Galaxy Health WC |
$309.23
|
| Rate for Payer: Global Benefits Group Commercial |
$218.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$327.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$231.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$214.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.76
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: Networks By Design Commercial |
$236.47
|
| Rate for Payer: Prime Health Services Commercial |
$309.23
|
|
|
RUXOLITINIB 25 MG TABLET [153890]
|
Facility
|
OP
|
$363.80
|
|
|
Service Code
|
NDC 5088102560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$72.76 |
| Max. Negotiated Rate |
$327.42 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$220.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$200.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$272.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$176.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$211.62
|
| Rate for Payer: Blue Shield of California Commercial |
$230.65
|
| Rate for Payer: Blue Shield of California EPN |
$145.16
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Central Health Plan Commercial |
$291.04
|
| Rate for Payer: Cigna of CA HMO |
$254.66
|
| Rate for Payer: Cigna of CA PPO |
$254.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$309.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$309.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$309.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$254.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.52
|
| Rate for Payer: EPIC Health Plan Senior |
$145.52
|
| Rate for Payer: Galaxy Health WC |
$309.23
|
| Rate for Payer: Global Benefits Group Commercial |
$218.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$327.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$231.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$132.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$214.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$254.66
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: Networks By Design Commercial |
$236.47
|
| Rate for Payer: Prime Health Services Commercial |
$309.23
|
| Rate for Payer: Riverside University Health System MISP |
$145.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$218.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$218.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$181.90
|
| Rate for Payer: United Healthcare All Other HMO |
$181.90
|
| Rate for Payer: United Healthcare HMO Rider |
$181.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$181.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$309.23
|
| Rate for Payer: Vantage Medical Group Senior |
$309.23
|
|
|
RUXOLITINIB 5 MG TABLET [153886]
|
Facility
|
IP
|
$363.80
|
|
|
Service Code
|
NDC 5088100560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$72.76 |
| Max. Negotiated Rate |
$327.42 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Blue Shield of California Commercial |
$291.77
|
| Rate for Payer: Blue Shield of California EPN |
$183.36
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Central Health Plan Commercial |
$291.04
|
| Rate for Payer: Cigna of CA HMO |
$254.66
|
| Rate for Payer: Cigna of CA PPO |
$254.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$254.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.52
|
| Rate for Payer: EPIC Health Plan Senior |
$145.52
|
| Rate for Payer: Galaxy Health WC |
$309.23
|
| Rate for Payer: Global Benefits Group Commercial |
$218.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$327.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$231.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$214.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.76
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: Networks By Design Commercial |
$236.47
|
| Rate for Payer: Prime Health Services Commercial |
$309.23
|
|
|
RUXOLITINIB 5 MG TABLET [153886]
|
Facility
|
OP
|
$363.80
|
|
|
Service Code
|
NDC 5088100560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$72.76 |
| Max. Negotiated Rate |
$327.42 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$220.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$200.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$272.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$176.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$211.62
|
| Rate for Payer: Blue Shield of California Commercial |
$230.65
|
| Rate for Payer: Blue Shield of California EPN |
$145.16
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Central Health Plan Commercial |
$291.04
|
| Rate for Payer: Cigna of CA HMO |
$254.66
|
| Rate for Payer: Cigna of CA PPO |
$254.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$309.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$309.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$309.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$254.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.52
|
| Rate for Payer: EPIC Health Plan Senior |
$145.52
|
| Rate for Payer: Galaxy Health WC |
$309.23
|
| Rate for Payer: Global Benefits Group Commercial |
$218.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$327.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$231.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$132.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$214.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$254.66
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: Networks By Design Commercial |
$236.47
|
| Rate for Payer: Prime Health Services Commercial |
$309.23
|
| Rate for Payer: Riverside University Health System MISP |
$145.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$218.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$218.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$181.90
|
| Rate for Payer: United Healthcare All Other HMO |
$181.90
|
| Rate for Payer: United Healthcare HMO Rider |
$181.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$181.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$309.23
|
| Rate for Payer: Vantage Medical Group Senior |
$309.23
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [227764]
|
Facility
|
OP
|
$3,137.72
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.64 |
| Max. Negotiated Rate |
$2,823.95 |
| Rate for Payer: Adventist Health Commercial |
$627.54
|
| Rate for Payer: Adventist Health Medi-Cal |
$37.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$70.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$56.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.64
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$55.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$68.99
|
| Rate for Payer: Blue Shield of California Commercial |
$45.18
|
| Rate for Payer: Blue Shield of California EPN |
$41.07
|
| Rate for Payer: Cash Price |
$1,411.97
|
| Rate for Payer: Cash Price |
$1,411.97
|
| Rate for Payer: Central Health Plan Commercial |
$2,510.18
|
| Rate for Payer: Cigna of CA HMO |
$2,196.40
|
| Rate for Payer: Cigna of CA PPO |
$2,196.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$41.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$41.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,196.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.11
|
| Rate for Payer: EPIC Health Plan Senior |
$41.40
|
| Rate for Payer: Galaxy Health WC |
$2,667.06
|
| Rate for Payer: Global Benefits Group Commercial |
$1,882.63
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,823.95
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$61.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$37.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37.64
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,992.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$70.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$52.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$627.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50.44
|
| Rate for Payer: Multiplan Commercial |
$2,353.29
|
| Rate for Payer: Networks By Design Commercial |
$1,568.86
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$37.64
|
| Rate for Payer: Prime Health Services Commercial |
$2,667.06
|
| Rate for Payer: Prime Health Services Medicare |
$39.90
|
| Rate for Payer: Riverside University Health System MISP |
$41.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,882.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,882.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,177.59
|
| Rate for Payer: United Healthcare All Other HMO |
$1,146.21
|
| Rate for Payer: United Healthcare HMO Rider |
$1,121.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,027.60
|
| Rate for Payer: Upland Medical Group Pediatric |
$37.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$47.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$41.40
|
| Rate for Payer: Vantage Medical Group Senior |
$41.40
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [227764]
|
Facility
|
IP
|
$3,137.72
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$627.54 |
| Max. Negotiated Rate |
$2,823.95 |
| Rate for Payer: Adventist Health Commercial |
$627.54
|
| Rate for Payer: Blue Shield of California Commercial |
$2,516.45
|
| Rate for Payer: Blue Shield of California EPN |
$1,581.41
|
| Rate for Payer: Cash Price |
$1,411.97
|
| Rate for Payer: Central Health Plan Commercial |
$2,510.18
|
| Rate for Payer: Cigna of CA HMO |
$2,196.40
|
| Rate for Payer: Cigna of CA PPO |
$2,196.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,196.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,255.09
|
| Rate for Payer: EPIC Health Plan Senior |
$1,255.09
|
| Rate for Payer: Galaxy Health WC |
$2,667.06
|
| Rate for Payer: Global Benefits Group Commercial |
$1,882.63
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,823.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,992.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,851.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$627.54
|
| Rate for Payer: Multiplan Commercial |
$2,353.29
|
| Rate for Payer: Networks By Design Commercial |
$1,568.86
|
| Rate for Payer: Prime Health Services Commercial |
$2,667.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,177.59
|
| Rate for Payer: United Healthcare All Other HMO |
$1,146.21
|
| Rate for Payer: United Healthcare HMO Rider |
$1,121.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,027.60
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 6233255660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.83
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Central Health Plan Commercial |
$1.31
|
| Rate for Payer: Cigna of CA HMO |
$1.15
|
| Rate for Payer: Cigna of CA PPO |
$1.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: EPIC Health Plan Senior |
$0.66
|
| Rate for Payer: Galaxy Health WC |
$1.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: Networks By Design Commercial |
$1.07
|
| Rate for Payer: Prime Health Services Commercial |
$1.39
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
OP
|
$14.53
|
|
|
Service Code
|
NDC 0078065920
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$13.08 |
| Rate for Payer: Adventist Health Commercial |
$2.91
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.45
|
| Rate for Payer: Blue Shield of California Commercial |
$9.21
|
| Rate for Payer: Blue Shield of California EPN |
$5.80
|
| Rate for Payer: Cash Price |
$6.54
|
| Rate for Payer: Central Health Plan Commercial |
$11.62
|
| Rate for Payer: Cigna of CA HMO |
$10.17
|
| Rate for Payer: Cigna of CA PPO |
$10.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.81
|
| Rate for Payer: EPIC Health Plan Senior |
$5.81
|
| Rate for Payer: Galaxy Health WC |
$12.35
|
| Rate for Payer: Global Benefits Group Commercial |
$8.72
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.17
|
| Rate for Payer: Multiplan Commercial |
$10.90
|
| Rate for Payer: Networks By Design Commercial |
$9.44
|
| Rate for Payer: Prime Health Services Commercial |
$12.35
|
| Rate for Payer: Riverside University Health System MISP |
$5.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.26
|
| Rate for Payer: United Healthcare All Other HMO |
$7.26
|
| Rate for Payer: United Healthcare HMO Rider |
$7.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.35
|
| Rate for Payer: Vantage Medical Group Senior |
$12.35
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
OP
|
$1.04
|
|
|
Service Code
|
NDC 3334257009
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Central Health Plan Commercial |
$0.83
|
| Rate for Payer: Cigna of CA HMO |
$0.73
|
| Rate for Payer: Cigna of CA PPO |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: EPIC Health Plan Senior |
$0.42
|
| Rate for Payer: Galaxy Health WC |
$0.88
|
| Rate for Payer: Global Benefits Group Commercial |
$0.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: Networks By Design Commercial |
$0.68
|
| Rate for Payer: Prime Health Services Commercial |
$0.88
|
| Rate for Payer: Riverside University Health System MISP |
$0.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.52
|
| Rate for Payer: United Healthcare All Other HMO |
$0.52
|
| Rate for Payer: United Healthcare HMO Rider |
$0.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Vantage Medical Group Senior |
$0.88
|
|
