|
BORTEZOMIB 3.5 MG SOLUTION FOR INJECTION SQ [40835839]
|
Facility
|
IP
|
$1,923.60
|
|
|
Service Code
|
HCPCS J9041
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$384.72 |
| Max. Negotiated Rate |
$1,731.24 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Blue Shield of California Commercial |
$1,542.73
|
| Rate for Payer: Blue Shield of California EPN |
$969.49
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Central Health Plan Commercial |
$1,538.88
|
| Rate for Payer: Cigna of CA HMO |
$1,346.52
|
| Rate for Payer: Cigna of CA PPO |
$1,346.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,346.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$769.44
|
| Rate for Payer: EPIC Health Plan Senior |
$769.44
|
| Rate for Payer: Galaxy Health WC |
$1,635.06
|
| Rate for Payer: Global Benefits Group Commercial |
$1,154.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,731.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,221.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,134.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$384.72
|
| Rate for Payer: Multiplan Commercial |
$1,442.70
|
| Rate for Payer: Networks By Design Commercial |
$961.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,635.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$721.93
|
| Rate for Payer: United Healthcare All Other HMO |
$702.69
|
| Rate for Payer: United Healthcare HMO Rider |
$687.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$629.98
|
|
|
BORTEZOMIB 3.5 MG SOLUTION FOR INJECTION SQ [40835839]
|
Facility
|
OP
|
$1,923.60
|
|
|
Service Code
|
HCPCS J9041
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$1,731.24 |
| Rate for Payer: Adventist Health Commercial |
$384.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,635.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,057.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,442.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$56.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$70.43
|
| Rate for Payer: Blue Shield of California Commercial |
$4.84
|
| Rate for Payer: Blue Shield of California EPN |
$4.40
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Central Health Plan Commercial |
$1,538.88
|
| Rate for Payer: Cigna of CA HMO |
$1,346.52
|
| Rate for Payer: Cigna of CA PPO |
$1,346.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,635.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,635.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,635.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,346.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$769.44
|
| Rate for Payer: EPIC Health Plan Senior |
$769.44
|
| Rate for Payer: Galaxy Health WC |
$1,635.06
|
| Rate for Payer: Global Benefits Group Commercial |
$1,154.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,731.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$2.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,221.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,134.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$384.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,346.52
|
| Rate for Payer: Multiplan Commercial |
$1,442.70
|
| Rate for Payer: Networks By Design Commercial |
$961.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,635.06
|
| Rate for Payer: Riverside University Health System MISP |
$769.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,154.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,154.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$721.93
|
| Rate for Payer: United Healthcare All Other HMO |
$702.69
|
| Rate for Payer: United Healthcare HMO Rider |
$687.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$629.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,635.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,635.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1,635.06
|
|
|
BOSENTAN 125 MG TABLET [31876]
|
Facility
|
OP
|
$17.45
|
|
|
Service Code
|
NDC 6838244714
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.15
|
| Rate for Payer: Blue Shield of California Commercial |
$11.06
|
| Rate for Payer: Blue Shield of California EPN |
$6.96
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: Central Health Plan Commercial |
$13.96
|
| Rate for Payer: Cigna of CA HMO |
$12.21
|
| Rate for Payer: Cigna of CA PPO |
$12.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: EPIC Health Plan Senior |
$6.98
|
| Rate for Payer: Galaxy Health WC |
$14.83
|
| Rate for Payer: Global Benefits Group Commercial |
$10.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.21
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
| Rate for Payer: Networks By Design Commercial |
$11.34
|
| Rate for Payer: Prime Health Services Commercial |
$14.83
|
| Rate for Payer: Riverside University Health System MISP |
$6.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.72
|
| Rate for Payer: United Healthcare All Other HMO |
$8.72
|
| Rate for Payer: United Healthcare HMO Rider |
$8.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.83
|
|
|
BOSENTAN 125 MG TABLET [31876]
|
Facility
|
IP
|
$17.45
|
|
|
Service Code
|
NDC 6838244714
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Blue Shield of California Commercial |
$13.99
|
| Rate for Payer: Blue Shield of California EPN |
$8.79
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: Central Health Plan Commercial |
$13.96
|
| Rate for Payer: Cigna of CA HMO |
$12.21
|
| Rate for Payer: Cigna of CA PPO |
$12.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: EPIC Health Plan Senior |
$6.98
|
| Rate for Payer: Galaxy Health WC |
$14.83
|
| Rate for Payer: Global Benefits Group Commercial |
$10.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.49
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
| Rate for Payer: Networks By Design Commercial |
$11.34
|
| Rate for Payer: Prime Health Services Commercial |
$14.83
|
|
|
BOSENTAN 31.25 MG 1/2 TABLET [4081538]
|
Facility
|
IP
|
$17.45
|
|
|
Service Code
|
NDC 6838244614
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Blue Shield of California Commercial |
$13.99
|
| Rate for Payer: Blue Shield of California EPN |
$8.79
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: Central Health Plan Commercial |
$13.96
|
| Rate for Payer: Cigna of CA HMO |
$12.21
|
| Rate for Payer: Cigna of CA PPO |
$12.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: EPIC Health Plan Senior |
$6.98
|
| Rate for Payer: Galaxy Health WC |
$14.83
|
| Rate for Payer: Global Benefits Group Commercial |
$10.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.49
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
| Rate for Payer: Networks By Design Commercial |
$11.34
|
| Rate for Payer: Prime Health Services Commercial |
$14.83
|
|
|
BOSENTAN 31.25 MG 1/2 TABLET [4081538]
|
Facility
|
OP
|
$17.45
|
|
|
Service Code
|
NDC 6838244614
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.15
|
| Rate for Payer: Blue Shield of California Commercial |
$11.06
|
| Rate for Payer: Blue Shield of California EPN |
$6.96
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: Central Health Plan Commercial |
$13.96
|
| Rate for Payer: Cigna of CA HMO |
$12.21
|
| Rate for Payer: Cigna of CA PPO |
$12.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: EPIC Health Plan Senior |
$6.98
|
| Rate for Payer: Galaxy Health WC |
$14.83
|
| Rate for Payer: Global Benefits Group Commercial |
$10.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.21
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
| Rate for Payer: Networks By Design Commercial |
$11.34
|
| Rate for Payer: Prime Health Services Commercial |
$14.83
|
| Rate for Payer: Riverside University Health System MISP |
$6.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.72
|
| Rate for Payer: United Healthcare All Other HMO |
$8.72
|
| Rate for Payer: United Healthcare HMO Rider |
$8.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.83
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$276.32
|
|
|
Service Code
|
NDC 6621510106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$248.69 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Blue Shield of California Commercial |
$221.61
|
| Rate for Payer: Blue Shield of California EPN |
$139.27
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Central Health Plan Commercial |
$221.06
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$248.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.26
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$276.32
|
|
|
Service Code
|
NDC 6621510106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$248.69 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$167.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$133.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$160.74
|
| Rate for Payer: Blue Shield of California Commercial |
$175.19
|
| Rate for Payer: Blue Shield of California EPN |
$110.25
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Central Health Plan Commercial |
$221.06
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$234.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$234.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$248.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$100.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$193.42
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
| Rate for Payer: Riverside University Health System MISP |
$110.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$165.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$165.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$138.16
|
| Rate for Payer: United Healthcare All Other HMO |
$138.16
|
| Rate for Payer: United Healthcare HMO Rider |
$138.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$138.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.87
|
| Rate for Payer: Vantage Medical Group Senior |
$234.87
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$17.45
|
|
|
Service Code
|
NDC 6838244614
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.15
|
| Rate for Payer: Blue Shield of California Commercial |
$11.06
|
| Rate for Payer: Blue Shield of California EPN |
$6.96
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: Central Health Plan Commercial |
$13.96
|
| Rate for Payer: Cigna of CA HMO |
$12.21
|
| Rate for Payer: Cigna of CA PPO |
$12.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: EPIC Health Plan Senior |
$6.98
|
| Rate for Payer: Galaxy Health WC |
$14.83
|
| Rate for Payer: Global Benefits Group Commercial |
$10.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.21
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
| Rate for Payer: Networks By Design Commercial |
$11.34
|
| Rate for Payer: Prime Health Services Commercial |
$14.83
|
| Rate for Payer: Riverside University Health System MISP |
$6.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.72
|
| Rate for Payer: United Healthcare All Other HMO |
$8.72
|
| Rate for Payer: United Healthcare HMO Rider |
$8.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.83
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$17.45
|
|
|
Service Code
|
NDC 6838244614
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Blue Shield of California Commercial |
$13.99
|
| Rate for Payer: Blue Shield of California EPN |
$8.79
|
| Rate for Payer: Cash Price |
$7.85
|
| Rate for Payer: Central Health Plan Commercial |
$13.96
|
| Rate for Payer: Cigna of CA HMO |
$12.21
|
| Rate for Payer: Cigna of CA PPO |
$12.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: EPIC Health Plan Senior |
$6.98
|
| Rate for Payer: Galaxy Health WC |
$14.83
|
| Rate for Payer: Global Benefits Group Commercial |
$10.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.49
|
| Rate for Payer: Multiplan Commercial |
$13.09
|
| Rate for Payer: Networks By Design Commercial |
$11.34
|
| Rate for Payer: Prime Health Services Commercial |
$14.83
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$276.32
|
|
|
Service Code
|
NDC 6621510103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$248.69 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$167.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$133.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$160.74
|
| Rate for Payer: Blue Shield of California Commercial |
$175.19
|
| Rate for Payer: Blue Shield of California EPN |
$110.25
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Central Health Plan Commercial |
$221.06
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$234.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$234.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$248.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$100.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$193.42
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
| Rate for Payer: Riverside University Health System MISP |
$110.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$165.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$165.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$138.16
|
| Rate for Payer: United Healthcare All Other HMO |
$138.16
|
| Rate for Payer: United Healthcare HMO Rider |
$138.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$138.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.87
|
| Rate for Payer: Vantage Medical Group Senior |
$234.87
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$276.32
|
|
|
Service Code
|
NDC 6621510103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$248.69 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Blue Shield of California Commercial |
$221.61
|
| Rate for Payer: Blue Shield of California EPN |
$139.27
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Central Health Plan Commercial |
$221.06
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$248.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.26
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
IP
|
$276.32
|
|
|
Service Code
|
NDC 6621510106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$248.69 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Blue Shield of California Commercial |
$221.61
|
| Rate for Payer: Blue Shield of California EPN |
$139.27
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Central Health Plan Commercial |
$221.06
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$248.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.26
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
OP
|
$276.32
|
|
|
Service Code
|
NDC 6621510103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$248.69 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$167.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$133.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$160.74
|
| Rate for Payer: Blue Shield of California Commercial |
$175.19
|
| Rate for Payer: Blue Shield of California EPN |
$110.25
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Central Health Plan Commercial |
$221.06
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$234.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$234.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$248.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$100.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$193.42
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
| Rate for Payer: Riverside University Health System MISP |
$110.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$165.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$165.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$138.16
|
| Rate for Payer: United Healthcare All Other HMO |
$138.16
|
| Rate for Payer: United Healthcare HMO Rider |
$138.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$138.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.87
|
| Rate for Payer: Vantage Medical Group Senior |
$234.87
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
IP
|
$276.32
|
|
|
Service Code
|
NDC 6621510103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$248.69 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Blue Shield of California Commercial |
$221.61
|
| Rate for Payer: Blue Shield of California EPN |
$139.27
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Central Health Plan Commercial |
$221.06
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$248.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.26
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
OP
|
$276.32
|
|
|
Service Code
|
NDC 6621510106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.26 |
| Max. Negotiated Rate |
$248.69 |
| Rate for Payer: Adventist Health Commercial |
$55.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$167.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$133.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$160.74
|
| Rate for Payer: Blue Shield of California Commercial |
$175.19
|
| Rate for Payer: Blue Shield of California EPN |
$110.25
|
| Rate for Payer: Cash Price |
$124.34
|
| Rate for Payer: Central Health Plan Commercial |
$221.06
|
| Rate for Payer: Cigna of CA HMO |
$193.42
|
| Rate for Payer: Cigna of CA PPO |
$193.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$234.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$234.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$193.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.53
|
| Rate for Payer: EPIC Health Plan Senior |
$110.53
|
| Rate for Payer: Galaxy Health WC |
$234.87
|
| Rate for Payer: Global Benefits Group Commercial |
$165.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$248.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$175.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$100.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$163.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$193.42
|
| Rate for Payer: Multiplan Commercial |
$207.24
|
| Rate for Payer: Networks By Design Commercial |
$179.61
|
| Rate for Payer: Prime Health Services Commercial |
$234.87
|
| Rate for Payer: Riverside University Health System MISP |
$110.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$165.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$165.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$138.16
|
| Rate for Payer: United Healthcare All Other HMO |
$138.16
|
| Rate for Payer: United Healthcare HMO Rider |
$138.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$138.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$234.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.87
|
| Rate for Payer: Vantage Medical Group Senior |
$234.87
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
|
IP
|
$16.44
|
|
|
Service Code
|
NDC 9940831876
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Blue Shield of California Commercial |
$13.18
|
| Rate for Payer: Blue Shield of California EPN |
$8.29
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: Central Health Plan Commercial |
$13.15
|
| Rate for Payer: Cigna of CA HMO |
$11.51
|
| Rate for Payer: Cigna of CA PPO |
$11.51
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.58
|
| Rate for Payer: EPIC Health Plan Senior |
$6.58
|
| Rate for Payer: Galaxy Health WC |
$13.97
|
| Rate for Payer: Global Benefits Group Commercial |
$9.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.29
|
| Rate for Payer: Multiplan Commercial |
$12.33
|
| Rate for Payer: Networks By Design Commercial |
$10.69
|
| Rate for Payer: Prime Health Services Commercial |
$13.97
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
|
OP
|
$16.44
|
|
|
Service Code
|
NDC 9940831876
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.33
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.56
|
| Rate for Payer: Blue Shield of California Commercial |
$10.42
|
| Rate for Payer: Blue Shield of California EPN |
$6.56
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: Central Health Plan Commercial |
$13.15
|
| Rate for Payer: Cigna of CA HMO |
$11.51
|
| Rate for Payer: Cigna of CA PPO |
$11.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.97
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.58
|
| Rate for Payer: EPIC Health Plan Senior |
$6.58
|
| Rate for Payer: Galaxy Health WC |
$13.97
|
| Rate for Payer: Global Benefits Group Commercial |
$9.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.51
|
| Rate for Payer: Multiplan Commercial |
$12.33
|
| Rate for Payer: Networks By Design Commercial |
$10.69
|
| Rate for Payer: Prime Health Services Commercial |
$13.97
|
| Rate for Payer: Riverside University Health System MISP |
$6.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.22
|
| Rate for Payer: United Healthcare All Other HMO |
$8.22
|
| Rate for Payer: United Healthcare HMO Rider |
$8.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.97
|
| Rate for Payer: Vantage Medical Group Senior |
$13.97
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
|
OP
|
$222.48
|
|
|
Service Code
|
NDC 0069013501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$200.23 |
| Rate for Payer: Adventist Health Commercial |
$44.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$135.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$189.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$122.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$166.86
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$107.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$129.42
|
| Rate for Payer: Blue Shield of California Commercial |
$141.05
|
| Rate for Payer: Blue Shield of California EPN |
$88.77
|
| Rate for Payer: Cash Price |
$100.12
|
| Rate for Payer: Central Health Plan Commercial |
$177.98
|
| Rate for Payer: Cigna of CA HMO |
$155.74
|
| Rate for Payer: Cigna of CA PPO |
$155.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$189.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$189.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$189.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$155.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.99
|
| Rate for Payer: EPIC Health Plan Senior |
$88.99
|
| Rate for Payer: Galaxy Health WC |
$189.11
|
| Rate for Payer: Global Benefits Group Commercial |
$133.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$200.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$141.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$80.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$131.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$155.74
|
| Rate for Payer: Multiplan Commercial |
$166.86
|
| Rate for Payer: Networks By Design Commercial |
$144.61
|
| Rate for Payer: Prime Health Services Commercial |
$189.11
|
| Rate for Payer: Riverside University Health System MISP |
$88.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$133.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$133.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$111.24
|
| Rate for Payer: United Healthcare All Other HMO |
$111.24
|
| Rate for Payer: United Healthcare HMO Rider |
$111.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$111.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$189.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$189.11
|
| Rate for Payer: Vantage Medical Group Senior |
$189.11
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
|
IP
|
$222.48
|
|
|
Service Code
|
NDC 0069013501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$200.23 |
| Rate for Payer: Adventist Health Commercial |
$44.50
|
| Rate for Payer: Blue Shield of California Commercial |
$178.43
|
| Rate for Payer: Blue Shield of California EPN |
$112.13
|
| Rate for Payer: Cash Price |
$100.12
|
| Rate for Payer: Central Health Plan Commercial |
$177.98
|
| Rate for Payer: Cigna of CA HMO |
$155.74
|
| Rate for Payer: Cigna of CA PPO |
$155.74
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$155.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.99
|
| Rate for Payer: EPIC Health Plan Senior |
$88.99
|
| Rate for Payer: Galaxy Health WC |
$189.11
|
| Rate for Payer: Global Benefits Group Commercial |
$133.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$200.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$141.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$131.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.50
|
| Rate for Payer: Multiplan Commercial |
$166.86
|
| Rate for Payer: Networks By Design Commercial |
$144.61
|
| Rate for Payer: Prime Health Services Commercial |
$189.11
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
|
IP
|
$889.92
|
|
|
Service Code
|
NDC 0069019301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$177.98 |
| Max. Negotiated Rate |
$800.93 |
| Rate for Payer: Adventist Health Commercial |
$177.98
|
| Rate for Payer: Blue Shield of California Commercial |
$713.72
|
| Rate for Payer: Blue Shield of California EPN |
$448.52
|
| Rate for Payer: Cash Price |
$400.46
|
| Rate for Payer: Central Health Plan Commercial |
$711.94
|
| Rate for Payer: Cigna of CA HMO |
$622.94
|
| Rate for Payer: Cigna of CA PPO |
$622.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$622.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$355.97
|
| Rate for Payer: EPIC Health Plan Senior |
$355.97
|
| Rate for Payer: Galaxy Health WC |
$756.43
|
| Rate for Payer: Global Benefits Group Commercial |
$533.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$800.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$565.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$525.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$177.98
|
| Rate for Payer: Multiplan Commercial |
$667.44
|
| Rate for Payer: Networks By Design Commercial |
$578.45
|
| Rate for Payer: Prime Health Services Commercial |
$756.43
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
|
OP
|
$889.92
|
|
|
Service Code
|
NDC 0069019301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$177.98 |
| Max. Negotiated Rate |
$800.93 |
| Rate for Payer: Adventist Health Commercial |
$177.98
|
| Rate for Payer: Aetna of CA HMO/PPO |
$540.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$756.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$489.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$667.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$430.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$517.67
|
| Rate for Payer: Blue Shield of California Commercial |
$564.21
|
| Rate for Payer: Blue Shield of California EPN |
$355.08
|
| Rate for Payer: Cash Price |
$400.46
|
| Rate for Payer: Central Health Plan Commercial |
$711.94
|
| Rate for Payer: Cigna of CA HMO |
$622.94
|
| Rate for Payer: Cigna of CA PPO |
$622.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$756.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$756.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$756.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$622.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$355.97
|
| Rate for Payer: EPIC Health Plan Senior |
$355.97
|
| Rate for Payer: Galaxy Health WC |
$756.43
|
| Rate for Payer: Global Benefits Group Commercial |
$533.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$800.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$565.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$323.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$525.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$177.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$622.94
|
| Rate for Payer: Multiplan Commercial |
$667.44
|
| Rate for Payer: Networks By Design Commercial |
$578.45
|
| Rate for Payer: Prime Health Services Commercial |
$756.43
|
| Rate for Payer: Riverside University Health System MISP |
$355.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$533.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$533.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$444.96
|
| Rate for Payer: United Healthcare All Other HMO |
$444.96
|
| Rate for Payer: United Healthcare HMO Rider |
$444.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$444.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$756.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$756.43
|
| Rate for Payer: Vantage Medical Group Senior |
$756.43
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
|
OP
|
$889.92
|
|
|
Service Code
|
NDC 0069013601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$177.98 |
| Max. Negotiated Rate |
$800.93 |
| Rate for Payer: Adventist Health Commercial |
$177.98
|
| Rate for Payer: Aetna of CA HMO/PPO |
$540.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$756.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$489.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$667.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$430.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$517.67
|
| Rate for Payer: Blue Shield of California Commercial |
$564.21
|
| Rate for Payer: Blue Shield of California EPN |
$355.08
|
| Rate for Payer: Cash Price |
$400.46
|
| Rate for Payer: Central Health Plan Commercial |
$711.94
|
| Rate for Payer: Cigna of CA HMO |
$622.94
|
| Rate for Payer: Cigna of CA PPO |
$622.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$756.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$756.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$756.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$622.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$355.97
|
| Rate for Payer: EPIC Health Plan Senior |
$355.97
|
| Rate for Payer: Galaxy Health WC |
$756.43
|
| Rate for Payer: Global Benefits Group Commercial |
$533.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$800.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$565.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$323.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$525.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$177.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$622.94
|
| Rate for Payer: Multiplan Commercial |
$667.44
|
| Rate for Payer: Networks By Design Commercial |
$578.45
|
| Rate for Payer: Prime Health Services Commercial |
$756.43
|
| Rate for Payer: Riverside University Health System MISP |
$355.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$533.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$533.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$444.96
|
| Rate for Payer: United Healthcare All Other HMO |
$444.96
|
| Rate for Payer: United Healthcare HMO Rider |
$444.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$444.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$756.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$756.43
|
| Rate for Payer: Vantage Medical Group Senior |
$756.43
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
|
IP
|
$889.92
|
|
|
Service Code
|
NDC 0069013601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$177.98 |
| Max. Negotiated Rate |
$800.93 |
| Rate for Payer: Adventist Health Commercial |
$177.98
|
| Rate for Payer: Blue Shield of California Commercial |
$713.72
|
| Rate for Payer: Blue Shield of California EPN |
$448.52
|
| Rate for Payer: Cash Price |
$400.46
|
| Rate for Payer: Central Health Plan Commercial |
$711.94
|
| Rate for Payer: Cigna of CA HMO |
$622.94
|
| Rate for Payer: Cigna of CA PPO |
$622.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$622.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$355.97
|
| Rate for Payer: EPIC Health Plan Senior |
$355.97
|
| Rate for Payer: Galaxy Health WC |
$756.43
|
| Rate for Payer: Global Benefits Group Commercial |
$533.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$800.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$565.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$525.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$177.98
|
| Rate for Payer: Multiplan Commercial |
$667.44
|
| Rate for Payer: Networks By Design Commercial |
$578.45
|
| Rate for Payer: Prime Health Services Commercial |
$756.43
|
|
|
BOTULISM IMMUNE GLOBULIN, HUMAN 100 MG INTRAVENOUS SOLUTION [213747]
|
Facility
|
IP
|
$271,800.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54,360.00 |
| Max. Negotiated Rate |
$244,620.00 |
| Rate for Payer: Adventist Health Commercial |
$54,360.00
|
| Rate for Payer: Blue Shield of California Commercial |
$217,983.60
|
| Rate for Payer: Blue Shield of California EPN |
$136,987.20
|
| Rate for Payer: Cash Price |
$122,310.00
|
| Rate for Payer: Central Health Plan Commercial |
$217,440.00
|
| Rate for Payer: Cigna of CA HMO |
$190,260.00
|
| Rate for Payer: Cigna of CA PPO |
$190,260.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$190,260.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$108,720.00
|
| Rate for Payer: EPIC Health Plan Senior |
$108,720.00
|
| Rate for Payer: Galaxy Health WC |
$231,030.00
|
| Rate for Payer: Global Benefits Group Commercial |
$163,080.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$244,620.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$172,593.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$160,362.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54,360.00
|
| Rate for Payer: Multiplan Commercial |
$203,850.00
|
| Rate for Payer: Networks By Design Commercial |
$135,900.00
|
| Rate for Payer: Prime Health Services Commercial |
$231,030.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$102,006.54
|
| Rate for Payer: United Healthcare All Other HMO |
$99,288.54
|
| Rate for Payer: United Healthcare HMO Rider |
$97,141.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$89,014.50
|
|
