|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 59762-0333-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Senior |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
NDC 70069-421-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
|
|
LECANEMAB-IRMB IN 0.9 % SODIUM CHLORIDE IV INFUSION [40820177]
|
Facility
|
OP
|
$152.88
|
|
|
Service Code
|
NDC 9940-8201-77
|
| Min. Negotiated Rate |
$27.67 |
| Max. Negotiated Rate |
$129.95 |
| Rate for Payer: Adventist Health Commercial |
$30.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$81.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$105.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$129.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$84.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$114.66
|
| Rate for Payer: Blue Shield of California Commercial |
$93.26
|
| Rate for Payer: Blue Shield of California EPN |
$74.61
|
| Rate for Payer: Cash Price |
$84.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$99.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$129.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$129.95
|
| Rate for Payer: Dignity Health Senior |
$129.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$94.63
|
| Rate for Payer: Heritage Provider Network Senior |
$94.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$72.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$107.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$107.02
|
| Rate for Payer: Multiplan Commercial |
$114.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$76.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$76.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$129.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$129.95
|
| Rate for Payer: Vantage Medical Group Senior |
$129.95
|
|
|
LECANEMAB-IRMB IN 0.9 % SODIUM CHLORIDE IV INFUSION [40820177]
|
Facility
|
IP
|
$152.88
|
|
|
Service Code
|
NDC 9940-8201-77
|
| Min. Negotiated Rate |
$27.67 |
| Max. Negotiated Rate |
$114.66 |
| Rate for Payer: Adventist Health Commercial |
$30.58
|
| Rate for Payer: Cash Price |
$84.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$103.50
|
| Rate for Payer: Heritage Provider Network Senior |
$103.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.22
|
| Rate for Payer: Multiplan Commercial |
$114.66
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 70710-1157-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: Dignity Health Senior |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 60505-2502-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.95
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: Dignity Health Senior |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.98
|
| Rate for Payer: Heritage Provider Network Senior |
$1.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Senior |
$1.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 70710-1157-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 60505-2502-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.17
|
| Rate for Payer: Heritage Provider Network Senior |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 23155-044-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$3.32
|
|
|
Service Code
|
NDC 60505-2503-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.49
|
| Rate for Payer: Blue Shield of California Commercial |
$2.03
|
| Rate for Payer: Blue Shield of California EPN |
$1.62
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.82
|
| Rate for Payer: Dignity Health Senior |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.06
|
| Rate for Payer: Heritage Provider Network Senior |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.32
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.33
|
| Rate for Payer: TriValley Medical Group Senior |
$1.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Vantage Medical Group Senior |
$2.82
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$3.32
|
|
|
Service Code
|
NDC 60505-2503-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.49 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.25
|
| Rate for Payer: Heritage Provider Network Senior |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 23155-044-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.75
|
| Rate for Payer: Dignity Health Senior |
$0.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.75
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 62332-062-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: Dignity Health Senior |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 62332-062-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
OP
|
$18.97
|
|
|
Service Code
|
NDC 0006-5004-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$16.12 |
| Rate for Payer: Adventist Health Commercial |
$3.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.23
|
| Rate for Payer: Blue Shield of California Commercial |
$11.57
|
| Rate for Payer: Blue Shield of California EPN |
$9.26
|
| Rate for Payer: Cash Price |
$10.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.12
|
| Rate for Payer: Dignity Health Senior |
$16.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.74
|
| Rate for Payer: Heritage Provider Network Senior |
$11.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.28
|
| Rate for Payer: Multiplan Commercial |
$14.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.12
|
| Rate for Payer: Vantage Medical Group Senior |
$16.12
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
OP
|
$18.97
|
|
|
Service Code
|
NDC 0006-5004-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$16.12 |
| Rate for Payer: Adventist Health Commercial |
$3.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.23
|
| Rate for Payer: Blue Shield of California Commercial |
$11.57
|
| Rate for Payer: Blue Shield of California EPN |
$9.26
|
| Rate for Payer: Cash Price |
$10.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.12
|
| Rate for Payer: Dignity Health Senior |
$16.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.74
|
| Rate for Payer: Heritage Provider Network Senior |
$11.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.28
|
| Rate for Payer: Multiplan Commercial |
$14.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.12
|
| Rate for Payer: Vantage Medical Group Senior |
$16.12
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
IP
|
$18.97
|
|
|
Service Code
|
NDC 0006-5004-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$14.23 |
| Rate for Payer: Adventist Health Commercial |
$3.79
|
| Rate for Payer: Cash Price |
$10.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.84
|
| Rate for Payer: Heritage Provider Network Senior |
$12.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.74
|
| Rate for Payer: Multiplan Commercial |
$14.23
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
IP
|
$18.97
|
|
|
Service Code
|
NDC 0006-5004-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$14.23 |
| Rate for Payer: Adventist Health Commercial |
$3.79
|
| Rate for Payer: Cash Price |
$10.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.84
|
| Rate for Payer: Heritage Provider Network Senior |
$12.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.74
|
| Rate for Payer: Multiplan Commercial |
$14.23
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
IP
|
$329.27
|
|
|
Service Code
|
NDC 0006-3076-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$59.60 |
| Max. Negotiated Rate |
$246.95 |
| Rate for Payer: Adventist Health Commercial |
$65.85
|
| Rate for Payer: Cash Price |
$181.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$177.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$222.92
|
| Rate for Payer: Heritage Provider Network Senior |
$222.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.32
|
| Rate for Payer: Multiplan Commercial |
$246.95
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
OP
|
$329.27
|
|
|
Service Code
|
NDC 0006-3076-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$59.60 |
| Max. Negotiated Rate |
$279.88 |
| Rate for Payer: Adventist Health Commercial |
$65.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$175.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$226.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$279.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$181.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$246.95
|
| Rate for Payer: Blue Shield of California Commercial |
$200.85
|
| Rate for Payer: Blue Shield of California EPN |
$160.68
|
| Rate for Payer: Cash Price |
$181.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$214.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$279.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$279.88
|
| Rate for Payer: Dignity Health Senior |
$279.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$210.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$203.82
|
| Rate for Payer: Heritage Provider Network Senior |
$203.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$157.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$230.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$230.49
|
| Rate for Payer: Multiplan Commercial |
$246.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$131.71
|
| Rate for Payer: TriValley Medical Group Senior |
$131.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$164.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$164.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$279.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$279.88
|
| Rate for Payer: Vantage Medical Group Senior |
$279.88
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
IP
|
$329.27
|
|
|
Service Code
|
NDC 0006-3076-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$59.60 |
| Max. Negotiated Rate |
$246.95 |
| Rate for Payer: Adventist Health Commercial |
$65.85
|
| Rate for Payer: Cash Price |
$181.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$177.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$222.92
|
| Rate for Payer: Heritage Provider Network Senior |
$222.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.32
|
| Rate for Payer: Multiplan Commercial |
$246.95
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
OP
|
$329.27
|
|
|
Service Code
|
NDC 0006-3076-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$59.60 |
| Max. Negotiated Rate |
$279.88 |
| Rate for Payer: Adventist Health Commercial |
$65.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$175.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$226.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$279.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$181.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$246.95
|
| Rate for Payer: Blue Shield of California Commercial |
$200.85
|
| Rate for Payer: Blue Shield of California EPN |
$160.68
|
| Rate for Payer: Cash Price |
$181.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$214.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$279.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$279.88
|
| Rate for Payer: Dignity Health Senior |
$279.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$210.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$203.82
|
| Rate for Payer: Heritage Provider Network Senior |
$203.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$157.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$230.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$230.49
|
| Rate for Payer: Multiplan Commercial |
$246.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$131.71
|
| Rate for Payer: TriValley Medical Group Senior |
$131.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$164.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$164.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$279.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$279.88
|
| Rate for Payer: Vantage Medical Group Senior |
$279.88
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Senior |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Senior |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 16729-034-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
