|
BORTEZOMIB 3.5 MG IV INJECTION. [408035839]
|
Facility
OP
|
$1,923.60
|
|
|
Service Code
|
CPT J9041
|
| Hospital Charge Code |
1755707
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$1,731.24 |
| Rate for Payer: Adventist Health Medi-Cal |
$1.96
|
| Rate for Payer: Adventist Health Medi-Cal |
$1.96
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$56.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$56.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.80
|
| Rate for Payer: BCBS Transplant Transplant |
$1,154.15
|
| Rate for Payer: BCBS Transplant Transplant |
$1,154.16
|
| Rate for Payer: Blue Shield of California Commercial |
$60.46
|
| Rate for Payer: Blue Shield of California Commercial |
$60.46
|
| Rate for Payer: Blue Shield of California EPN |
$54.96
|
| Rate for Payer: Blue Shield of California EPN |
$54.96
|
| Rate for Payer: Caremore Medicare Advantage |
$1.96
|
| Rate for Payer: Caremore Medicare Advantage |
$1.96
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Central Health Plan Commercial |
$1,538.88
|
| Rate for Payer: Central Health Plan Commercial |
$1,538.86
|
| Rate for Payer: Cigna of CA HMO |
$1,346.51
|
| Rate for Payer: Cigna of CA HMO |
$1,346.52
|
| Rate for Payer: Cigna of CA PPO |
$1,346.51
|
| Rate for Payer: Cigna of CA PPO |
$1,346.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.64
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.96
|
| Rate for Payer: Galaxy Health WC |
$1,635.04
|
| Rate for Payer: Galaxy Health WC |
$1,635.06
|
| Rate for Payer: Global Benefits Group Commercial |
$1,154.16
|
| Rate for Payer: Global Benefits Group Commercial |
$1,154.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,731.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,731.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,442.68
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,442.70
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3.21
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3.21
|
| Rate for Payer: IEHP medi-cal |
$3.23
|
| Rate for Payer: IEHP medi-cal |
$3.23
|
| Rate for Payer: IEHP Medicare Advantage |
$1.96
|
| Rate for Payer: IEHP Medicare Advantage |
$1.96
|
| Rate for Payer: Innovage PACE Commercial |
$2.94
|
| Rate for Payer: Innovage PACE Commercial |
$2.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,283.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,283.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$384.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$384.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.63
|
| Rate for Payer: Multiplan Commercial |
$1,442.70
|
| Rate for Payer: Multiplan Commercial |
$1,442.68
|
| Rate for Payer: Networks By Design Commercial |
$961.79
|
| Rate for Payer: Networks By Design Commercial |
$961.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,635.06
|
| Rate for Payer: Prime Health Services Commercial |
$1,635.04
|
| Rate for Payer: Prime Health Services Medicare |
$2.08
|
| Rate for Payer: Prime Health Services Medicare |
$2.08
|
| Rate for Payer: Riverside University Health MISP |
$2.15
|
| Rate for Payer: Riverside University Health MISP |
$2.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,154.15
|
| 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: TriValley Medical Group Commercial/Senior |
$1,154.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$961.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$961.79
|
| Rate for Payer: United Healthcare All Other HMO |
$961.80
|
| Rate for Payer: United Healthcare All Other HMO |
$961.79
|
| Rate for Payer: United Healthcare HMO Rider |
$961.79
|
| Rate for Payer: United Healthcare HMO Rider |
$961.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$961.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$961.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1.96
|
| Rate for Payer: Vantage Medical Group Senior |
$1.96
|
|
|
BORTEZOMIB 3.5 MG IV INJECTION. [408035839]
|
Facility
IP
|
$1,923.58
|
|
|
Service Code
|
CPT J9041
|
| Hospital Charge Code |
1755707
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$384.72 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1,442.68
|
| Rate for Payer: Blue Shield of California Commercial |
$1,442.70
|
| Rate for Payer: Blue Shield of California EPN |
$1,027.19
|
| Rate for Payer: Blue Shield of California EPN |
$1,027.20
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Cash Price |
$865.61
|
| Rate for Payer: Cash Price |
$865.62
|
| Rate for Payer: Central Health Plan Commercial |
$1,538.86
|
| Rate for Payer: Central Health Plan Commercial |
$1,538.88
|
| Rate for Payer: Cigna of CA HMO |
$1,346.51
|
| Rate for Payer: Cigna of CA HMO |
$1,346.52
|
| Rate for Payer: Cigna of CA PPO |
$1,346.51
|
| Rate for Payer: Cigna of CA PPO |
$1,346.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$769.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$769.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$769.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$769.43
|
| Rate for Payer: Galaxy Health WC |
$1,635.04
|
| Rate for Payer: Galaxy Health WC |
$1,635.06
|
| Rate for Payer: Global Benefits Group Commercial |
$1,154.15
|
| Rate for Payer: Global Benefits Group Commercial |
$1,154.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,731.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,731.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,283.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,283.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$384.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$384.72
|
| Rate for Payer: Multiplan Commercial |
$1,442.70
|
| Rate for Payer: Multiplan Commercial |
$1,442.68
|
| Rate for Payer: Networks By Design Commercial |
$961.79
|
| Rate for Payer: Networks By Design Commercial |
$961.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,635.06
|
| Rate for Payer: Prime Health Services Commercial |
$1,635.04
|
|
|
BORTEZOMIB 3.5 MG SOLUTION FOR INJECTION SQ [40835839]
|
Facility
OP
|
$1,923.60
|
|
|
Service Code
|
CPT J9041
|
| Hospital Charge Code |
ERX40835839
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$1,731.24 |
| Rate for Payer: Adventist Health Medi-Cal |
$1.96
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$56.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.80
|
| Rate for Payer: BCBS Transplant Transplant |
$1,154.16
|
| Rate for Payer: Blue Shield of California Commercial |
$60.46
|
| Rate for Payer: Blue Shield of California EPN |
$54.96
|
| Rate for Payer: Caremore Medicare Advantage |
$1.96
|
| 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 |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.64
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.96
|
| 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: Health Plan of Nevada - Sierra Transplant Other |
$1,442.70
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3.21
|
| Rate for Payer: IEHP medi-cal |
$3.23
|
| Rate for Payer: IEHP Medicare Advantage |
$1.96
|
| Rate for Payer: Innovage PACE Commercial |
$2.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,283.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$384.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.63
|
| 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: Prime Health Services Medicare |
$2.08
|
| Rate for Payer: Riverside University Health MISP |
$2.15
|
| 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 |
$961.80
|
| Rate for Payer: United Healthcare All Other HMO |
$961.80
|
| Rate for Payer: United Healthcare HMO Rider |
$961.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$961.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1.96
|
|
|
BORTEZOMIB 3.5 MG SOLUTION FOR INJECTION SQ [40835839]
|
Facility
IP
|
$1,923.60
|
|
|
Service Code
|
CPT J9041
|
| Hospital Charge Code |
ERX40835839
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$384.72 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1,442.70
|
| Rate for Payer: Blue Shield of California EPN |
$1,027.20
|
| 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: EPIC Health Plan Commercial |
$769.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$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 Permanente of CA Commercial/Self Funded |
$1,283.04
|
| 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
|
|
|
BOSENTAN 125 MG TABLET [31876]
|
Facility
IP
|
$23.26
|
|
|
Service Code
|
NDC 68382-447-14
|
| Hospital Charge Code |
1710988
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$17.44
|
| Rate for Payer: Blue Shield of California EPN |
$12.42
|
| Rate for Payer: Cash Price |
$10.47
|
| Rate for Payer: Cash Price |
$10.47
|
| Rate for Payer: Central Health Plan Commercial |
$18.61
|
| Rate for Payer: Cigna of CA HMO |
$16.28
|
| Rate for Payer: Cigna of CA PPO |
$16.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.30
|
| Rate for Payer: Galaxy Health WC |
$19.77
|
| Rate for Payer: Global Benefits Group Commercial |
$13.96
|
| Rate for Payer: Health Management Network EPO/PPO |
$20.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.65
|
| Rate for Payer: Multiplan Commercial |
$17.44
|
| Rate for Payer: Networks By Design Commercial |
$15.12
|
| Rate for Payer: Prime Health Services Commercial |
$19.77
|
|
|
BOSENTAN 125 MG TABLET [31876]
|
Facility
OP
|
$23.26
|
|
|
Service Code
|
NDC 68382-447-14
|
| Hospital Charge Code |
1710988
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$20.93 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.79
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$11.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.74
|
| Rate for Payer: BCBS Transplant Transplant |
$13.96
|
| Rate for Payer: Blue Shield of California Commercial |
$14.63
|
| Rate for Payer: Blue Shield of California EPN |
$11.37
|
| Rate for Payer: Cash Price |
$10.47
|
| Rate for Payer: Central Health Plan Commercial |
$18.61
|
| Rate for Payer: Cigna of CA HMO |
$16.28
|
| Rate for Payer: Cigna of CA PPO |
$16.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.30
|
| Rate for Payer: Galaxy Health WC |
$19.77
|
| Rate for Payer: Global Benefits Group Commercial |
$13.96
|
| Rate for Payer: Health Management Network EPO/PPO |
$20.93
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$17.44
|
| Rate for Payer: IEHP medi-cal |
$8.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.65
|
| Rate for Payer: Multiplan Commercial |
$17.44
|
| Rate for Payer: Networks By Design Commercial |
$15.12
|
| Rate for Payer: Prime Health Services Commercial |
$19.77
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.96
|
| Rate for Payer: Riverside University Health MISP |
$9.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.63
|
| Rate for Payer: United Healthcare All Other HMO |
$11.63
|
| Rate for Payer: United Healthcare HMO Rider |
$11.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.77
|
| Rate for Payer: Vantage Medical Group Senior |
$19.77
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
OP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
1710987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$209.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$141.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$197.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$127.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$127.95
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$112.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$137.44
|
| Rate for Payer: BCBS Transplant Transplant |
$139.58
|
| Rate for Payer: Blue Shield of California Commercial |
$146.32
|
| Rate for Payer: Blue Shield of California EPN |
$113.76
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Central Health Plan Commercial |
$186.10
|
| Rate for Payer: Cigna of CA HMO |
$162.84
|
| Rate for Payer: Cigna of CA PPO |
$162.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$197.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$93.05
|
| Rate for Payer: Galaxy Health WC |
$197.74
|
| Rate for Payer: Global Benefits Group Commercial |
$139.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$209.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$174.47
|
| Rate for Payer: IEHP medi-cal |
$81.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$155.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.53
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
| Rate for Payer: Networks By Design Commercial |
$151.21
|
| Rate for Payer: Prime Health Services Commercial |
$197.74
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$139.58
|
| Rate for Payer: Riverside University Health MISP |
$93.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$139.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$139.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$116.32
|
| Rate for Payer: United Healthcare All Other HMO |
$116.32
|
| Rate for Payer: United Healthcare HMO Rider |
$116.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$116.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$197.74
|
| Rate for Payer: Vantage Medical Group Senior |
$197.74
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
IP
|
$23.26
|
|
|
Service Code
|
NDC 68382-446-14
|
| Hospital Charge Code |
1710987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$17.44
|
| Rate for Payer: Blue Shield of California EPN |
$12.42
|
| Rate for Payer: Cash Price |
$10.47
|
| Rate for Payer: Cash Price |
$10.47
|
| Rate for Payer: Central Health Plan Commercial |
$18.61
|
| Rate for Payer: Cigna of CA HMO |
$16.28
|
| Rate for Payer: Cigna of CA PPO |
$16.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.30
|
| Rate for Payer: Galaxy Health WC |
$19.77
|
| Rate for Payer: Global Benefits Group Commercial |
$13.96
|
| Rate for Payer: Health Management Network EPO/PPO |
$20.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.65
|
| Rate for Payer: Multiplan Commercial |
$17.44
|
| Rate for Payer: Networks By Design Commercial |
$15.12
|
| Rate for Payer: Prime Health Services Commercial |
$19.77
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
IP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
1710987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$174.47
|
| Rate for Payer: Blue Shield of California EPN |
$124.22
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Central Health Plan Commercial |
$186.10
|
| Rate for Payer: Cigna of CA HMO |
$162.84
|
| Rate for Payer: Cigna of CA PPO |
$162.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.05
|
| Rate for Payer: Galaxy Health WC |
$197.74
|
| Rate for Payer: Global Benefits Group Commercial |
$139.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$209.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$155.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.53
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
| Rate for Payer: Networks By Design Commercial |
$151.21
|
| Rate for Payer: Prime Health Services Commercial |
$197.74
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
OP
|
$23.26
|
|
|
Service Code
|
NDC 68382-446-14
|
| Hospital Charge Code |
1710987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$20.93 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.79
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$11.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.74
|
| Rate for Payer: BCBS Transplant Transplant |
$13.96
|
| Rate for Payer: Blue Shield of California Commercial |
$14.63
|
| Rate for Payer: Blue Shield of California EPN |
$11.37
|
| Rate for Payer: Cash Price |
$10.47
|
| Rate for Payer: Central Health Plan Commercial |
$18.61
|
| Rate for Payer: Cigna of CA HMO |
$16.28
|
| Rate for Payer: Cigna of CA PPO |
$16.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.30
|
| Rate for Payer: Galaxy Health WC |
$19.77
|
| Rate for Payer: Global Benefits Group Commercial |
$13.96
|
| Rate for Payer: Health Management Network EPO/PPO |
$20.93
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$17.44
|
| Rate for Payer: IEHP medi-cal |
$8.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.65
|
| Rate for Payer: Multiplan Commercial |
$17.44
|
| Rate for Payer: Networks By Design Commercial |
$15.12
|
| Rate for Payer: Prime Health Services Commercial |
$19.77
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.96
|
| Rate for Payer: Riverside University Health MISP |
$9.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.63
|
| Rate for Payer: United Healthcare All Other HMO |
$11.63
|
| Rate for Payer: United Healthcare HMO Rider |
$11.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.77
|
| Rate for Payer: Vantage Medical Group Senior |
$19.77
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
IP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
1710987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$174.47
|
| Rate for Payer: Blue Shield of California EPN |
$124.22
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Central Health Plan Commercial |
$186.10
|
| Rate for Payer: Cigna of CA HMO |
$162.84
|
| Rate for Payer: Cigna of CA PPO |
$162.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.05
|
| Rate for Payer: Galaxy Health WC |
$197.74
|
| Rate for Payer: Global Benefits Group Commercial |
$139.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$209.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$155.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.53
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
| Rate for Payer: Networks By Design Commercial |
$151.21
|
| Rate for Payer: Prime Health Services Commercial |
$197.74
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
OP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
1710987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$209.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$141.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$197.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$127.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$127.95
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$112.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$137.44
|
| Rate for Payer: BCBS Transplant Transplant |
$139.58
|
| Rate for Payer: Blue Shield of California Commercial |
$146.32
|
| Rate for Payer: Blue Shield of California EPN |
$113.76
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Central Health Plan Commercial |
$186.10
|
| Rate for Payer: Cigna of CA HMO |
$162.84
|
| Rate for Payer: Cigna of CA PPO |
$162.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$197.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$93.05
|
| Rate for Payer: Galaxy Health WC |
$197.74
|
| Rate for Payer: Global Benefits Group Commercial |
$139.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$209.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$174.47
|
| Rate for Payer: IEHP medi-cal |
$81.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$155.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.53
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
| Rate for Payer: Networks By Design Commercial |
$151.21
|
| Rate for Payer: Prime Health Services Commercial |
$197.74
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$139.58
|
| Rate for Payer: Riverside University Health MISP |
$93.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$139.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$139.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$116.32
|
| Rate for Payer: United Healthcare All Other HMO |
$116.32
|
| Rate for Payer: United Healthcare HMO Rider |
$116.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$116.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$197.74
|
| Rate for Payer: Vantage Medical Group Senior |
$197.74
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
IP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
ERX40831875
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$174.47
|
| Rate for Payer: Blue Shield of California EPN |
$124.22
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Central Health Plan Commercial |
$186.10
|
| Rate for Payer: Cigna of CA HMO |
$162.84
|
| Rate for Payer: Cigna of CA PPO |
$162.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.05
|
| Rate for Payer: Galaxy Health WC |
$197.74
|
| Rate for Payer: Global Benefits Group Commercial |
$139.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$209.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$155.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.53
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
| Rate for Payer: Networks By Design Commercial |
$151.21
|
| Rate for Payer: Prime Health Services Commercial |
$197.74
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
OP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
ERX40831875
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$209.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$141.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$197.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$127.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$127.95
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$112.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$137.44
|
| Rate for Payer: BCBS Transplant Transplant |
$139.58
|
| Rate for Payer: Blue Shield of California Commercial |
$146.32
|
| Rate for Payer: Blue Shield of California EPN |
$113.76
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Central Health Plan Commercial |
$186.10
|
| Rate for Payer: Cigna of CA HMO |
$162.84
|
| Rate for Payer: Cigna of CA PPO |
$162.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$197.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$93.05
|
| Rate for Payer: Galaxy Health WC |
$197.74
|
| Rate for Payer: Global Benefits Group Commercial |
$139.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$209.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$174.47
|
| Rate for Payer: IEHP medi-cal |
$81.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$155.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.53
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
| Rate for Payer: Networks By Design Commercial |
$151.21
|
| Rate for Payer: Prime Health Services Commercial |
$197.74
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$139.58
|
| Rate for Payer: Riverside University Health MISP |
$93.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$139.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$139.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$116.32
|
| Rate for Payer: United Healthcare All Other HMO |
$116.32
|
| Rate for Payer: United Healthcare HMO Rider |
$116.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$116.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$197.74
|
| Rate for Payer: Vantage Medical Group Senior |
$197.74
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
IP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
ERX40831875
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$174.47
|
| Rate for Payer: Blue Shield of California EPN |
$124.22
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Central Health Plan Commercial |
$186.10
|
| Rate for Payer: Cigna of CA HMO |
$162.84
|
| Rate for Payer: Cigna of CA PPO |
$162.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.05
|
| Rate for Payer: Galaxy Health WC |
$197.74
|
| Rate for Payer: Global Benefits Group Commercial |
$139.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$209.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$155.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.53
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
| Rate for Payer: Networks By Design Commercial |
$151.21
|
| Rate for Payer: Prime Health Services Commercial |
$197.74
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
OP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
ERX40831875
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$209.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$141.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$197.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$127.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$127.95
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$112.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$137.44
|
| Rate for Payer: BCBS Transplant Transplant |
$139.58
|
| Rate for Payer: Blue Shield of California Commercial |
$146.32
|
| Rate for Payer: Blue Shield of California EPN |
$113.76
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Central Health Plan Commercial |
$186.10
|
| Rate for Payer: Cigna of CA HMO |
$162.84
|
| Rate for Payer: Cigna of CA PPO |
$162.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$197.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$93.05
|
| Rate for Payer: Galaxy Health WC |
$197.74
|
| Rate for Payer: Global Benefits Group Commercial |
$139.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$209.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$174.47
|
| Rate for Payer: IEHP medi-cal |
$81.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$155.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.53
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
| Rate for Payer: Networks By Design Commercial |
$151.21
|
| Rate for Payer: Prime Health Services Commercial |
$197.74
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$139.58
|
| Rate for Payer: Riverside University Health MISP |
$93.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$139.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$139.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$116.32
|
| Rate for Payer: United Healthcare All Other HMO |
$116.32
|
| Rate for Payer: United Healthcare HMO Rider |
$116.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$116.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$197.74
|
| Rate for Payer: Vantage Medical Group Senior |
$197.74
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
IP
|
$16.44
|
|
|
Service Code
|
NDC 9940-8318-76
|
| Hospital Charge Code |
NDC40831876
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$12.33
|
| Rate for Payer: Blue Shield of California EPN |
$8.78
|
| Rate for Payer: Cash Price |
$7.40
|
| 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: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$10.97
|
| 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 9940-8318-76
|
| Hospital Charge Code |
NDC40831876
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.71
|
| Rate for Payer: BCBS Transplant Transplant |
$9.86
|
| Rate for Payer: Blue Shield of California Commercial |
$10.34
|
| Rate for Payer: Blue Shield of California EPN |
$8.04
|
| 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: EPIC Health Plan Commercial |
$6.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$12.33
|
| Rate for Payer: IEHP medi-cal |
$5.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.97
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$9.86
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$13.97
|
| Rate for Payer: Vantage Medical Group Senior |
$13.97
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
OP
|
$194.83
|
|
|
Service Code
|
NDC 0069-0135-01
|
| Hospital Charge Code |
ERX197246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.97 |
| Max. Negotiated Rate |
$175.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$118.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$165.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$107.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$107.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$94.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$115.11
|
| Rate for Payer: BCBS Transplant Transplant |
$116.90
|
| Rate for Payer: Blue Shield of California Commercial |
$122.55
|
| Rate for Payer: Blue Shield of California EPN |
$95.27
|
| Rate for Payer: Cash Price |
$87.67
|
| Rate for Payer: Central Health Plan Commercial |
$155.86
|
| Rate for Payer: Cigna of CA HMO |
$136.38
|
| Rate for Payer: Cigna of CA PPO |
$136.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$165.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$77.93
|
| Rate for Payer: EPIC Health Plan Transplant |
$77.93
|
| Rate for Payer: Galaxy Health WC |
$165.61
|
| Rate for Payer: Global Benefits Group Commercial |
$116.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$175.35
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$146.12
|
| Rate for Payer: IEHP medi-cal |
$68.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$129.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.97
|
| Rate for Payer: Multiplan Commercial |
$146.12
|
| Rate for Payer: Networks By Design Commercial |
$126.64
|
| Rate for Payer: Prime Health Services Commercial |
$165.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$116.90
|
| Rate for Payer: Riverside University Health MISP |
$77.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$116.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$116.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$97.42
|
| Rate for Payer: United Healthcare All Other HMO |
$97.42
|
| Rate for Payer: United Healthcare HMO Rider |
$97.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$97.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$165.61
|
| Rate for Payer: Vantage Medical Group Senior |
$165.61
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
IP
|
$194.83
|
|
|
Service Code
|
NDC 0069-0135-01
|
| Hospital Charge Code |
ERX197246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.97 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$146.12
|
| Rate for Payer: Blue Shield of California EPN |
$104.04
|
| Rate for Payer: Cash Price |
$87.67
|
| Rate for Payer: Cash Price |
$87.67
|
| Rate for Payer: Central Health Plan Commercial |
$155.86
|
| Rate for Payer: Cigna of CA HMO |
$136.38
|
| Rate for Payer: Cigna of CA PPO |
$136.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$77.93
|
| Rate for Payer: Galaxy Health WC |
$165.61
|
| Rate for Payer: Global Benefits Group Commercial |
$116.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$175.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$129.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.97
|
| Rate for Payer: Multiplan Commercial |
$146.12
|
| Rate for Payer: Networks By Design Commercial |
$126.64
|
| Rate for Payer: Prime Health Services Commercial |
$165.61
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
IP
|
$779.30
|
|
|
Service Code
|
NDC 0069-0193-01
|
| Hospital Charge Code |
ERX220449
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$155.86 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$584.48
|
| Rate for Payer: Blue Shield of California EPN |
$416.15
|
| Rate for Payer: Cash Price |
$350.69
|
| Rate for Payer: Cash Price |
$350.69
|
| Rate for Payer: Central Health Plan Commercial |
$623.44
|
| Rate for Payer: Cigna of CA HMO |
$545.51
|
| Rate for Payer: Cigna of CA PPO |
$545.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$311.72
|
| Rate for Payer: Galaxy Health WC |
$662.40
|
| Rate for Payer: Global Benefits Group Commercial |
$467.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$701.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$519.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.86
|
| Rate for Payer: Multiplan Commercial |
$584.48
|
| Rate for Payer: Networks By Design Commercial |
$506.54
|
| Rate for Payer: Prime Health Services Commercial |
$662.40
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
OP
|
$779.30
|
|
|
Service Code
|
NDC 0069-0193-01
|
| Hospital Charge Code |
ERX220449
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$155.86 |
| Max. Negotiated Rate |
$701.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$473.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$662.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$428.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$428.62
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$377.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$460.41
|
| Rate for Payer: BCBS Transplant Transplant |
$467.58
|
| Rate for Payer: Blue Shield of California Commercial |
$490.18
|
| Rate for Payer: Blue Shield of California EPN |
$381.08
|
| Rate for Payer: Cash Price |
$350.69
|
| Rate for Payer: Central Health Plan Commercial |
$623.44
|
| Rate for Payer: Cigna of CA HMO |
$545.51
|
| Rate for Payer: Cigna of CA PPO |
$545.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$662.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$311.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$311.72
|
| Rate for Payer: Galaxy Health WC |
$662.40
|
| Rate for Payer: Global Benefits Group Commercial |
$467.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$701.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$584.48
|
| Rate for Payer: IEHP medi-cal |
$272.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$519.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.86
|
| Rate for Payer: Multiplan Commercial |
$584.48
|
| Rate for Payer: Networks By Design Commercial |
$506.54
|
| Rate for Payer: Prime Health Services Commercial |
$662.40
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$467.58
|
| Rate for Payer: Riverside University Health MISP |
$311.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$467.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$467.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$389.65
|
| Rate for Payer: United Healthcare All Other HMO |
$389.65
|
| Rate for Payer: United Healthcare HMO Rider |
$389.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$389.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$662.40
|
| Rate for Payer: Vantage Medical Group Senior |
$662.40
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
OP
|
$779.30
|
|
|
Service Code
|
NDC 0069-0136-01
|
| Hospital Charge Code |
ERX197247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$155.86 |
| Max. Negotiated Rate |
$701.37 |
| Rate for Payer: IEHP medi-cal |
$272.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$473.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$662.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$428.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$428.62
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$377.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$460.41
|
| Rate for Payer: BCBS Transplant Transplant |
$467.58
|
| Rate for Payer: Blue Shield of California Commercial |
$490.18
|
| Rate for Payer: Blue Shield of California EPN |
$381.08
|
| Rate for Payer: Cash Price |
$350.69
|
| Rate for Payer: Central Health Plan Commercial |
$623.44
|
| Rate for Payer: Cigna of CA HMO |
$545.51
|
| Rate for Payer: Cigna of CA PPO |
$545.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$662.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$311.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$311.72
|
| Rate for Payer: Galaxy Health WC |
$662.40
|
| Rate for Payer: Global Benefits Group Commercial |
$467.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$701.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$584.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$519.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.86
|
| Rate for Payer: Multiplan Commercial |
$584.48
|
| Rate for Payer: Networks By Design Commercial |
$506.54
|
| Rate for Payer: Prime Health Services Commercial |
$662.40
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$467.58
|
| Rate for Payer: Riverside University Health MISP |
$311.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$467.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$467.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$389.65
|
| Rate for Payer: United Healthcare All Other HMO |
$389.65
|
| Rate for Payer: United Healthcare HMO Rider |
$389.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$389.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$662.40
|
| Rate for Payer: Vantage Medical Group Senior |
$662.40
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
IP
|
$779.30
|
|
|
Service Code
|
NDC 0069-0136-01
|
| Hospital Charge Code |
ERX197247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$155.86 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$584.48
|
| Rate for Payer: Blue Shield of California EPN |
$416.15
|
| Rate for Payer: Cash Price |
$350.69
|
| Rate for Payer: Cash Price |
$350.69
|
| Rate for Payer: Central Health Plan Commercial |
$623.44
|
| Rate for Payer: Cigna of CA HMO |
$545.51
|
| Rate for Payer: Cigna of CA PPO |
$545.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$311.72
|
| Rate for Payer: Galaxy Health WC |
$662.40
|
| Rate for Payer: Global Benefits Group Commercial |
$467.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$701.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$519.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.86
|
| Rate for Payer: Multiplan Commercial |
$584.48
|
| Rate for Payer: Networks By Design Commercial |
$506.54
|
| Rate for Payer: Prime Health Services Commercial |
$662.40
|
|
|
BOTULISM IMMUNE GLOBULIN, HUMAN 100 MG INTRAVENOUS SOLUTION [213747]
|
Facility
OP
|
$271,800.00
|
|
|
Service Code
|
NDC 68403-1100-6
|
| Hospital Charge Code |
NDG213747
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54,360.00 |
| Max. Negotiated Rate |
$244,620.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$165,064.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$231,030.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$149,490.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$149,490.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$131,605.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$160,579.44
|
| Rate for Payer: BCBS Transplant Transplant |
$163,080.00
|
| Rate for Payer: Blue Shield of California Commercial |
$170,962.20
|
| Rate for Payer: Blue Shield of California EPN |
$132,910.20
|
| Rate for Payer: Cash Price |
$122,310.00
|
| 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: Dignity Health Commercial/Exchange |
$231,030.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$108,720.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$203,850.00
|
| Rate for Payer: IEHP medi-cal |
$95,130.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$181,290.60
|
| 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: Riverside University Health MISP |
$108,720.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$163,080.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$163,080.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$135,900.00
|
| Rate for Payer: United Healthcare All Other HMO |
$135,900.00
|
| Rate for Payer: United Healthcare HMO Rider |
$135,900.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$135,900.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231,030.00
|
| Rate for Payer: Vantage Medical Group Senior |
$231,030.00
|
|
