|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
OP
|
$5.14
|
|
|
Service Code
|
NDC 6131454701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.57
|
| Rate for Payer: Blue Shield of California Commercial |
$3.14
|
| Rate for Payer: Blue Shield of California EPN |
$2.51
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.18
|
| Rate for Payer: Heritage Provider Network Senior |
$3.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.06
|
| Rate for Payer: TriValley Medical Group Senior |
$2.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.37
|
| Rate for Payer: Vantage Medical Group Senior |
$4.37
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
OP
|
$2.38
|
|
|
Service Code
|
NDC 7006942101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.19
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.67
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Senior |
$0.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.02
|
| Rate for Payer: Vantage Medical Group Senior |
$2.02
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
NDC 7006942101
|
| 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: Aetna of CA Non-Gatekeeper |
$1.53
|
| Rate for Payer: Cash Price |
$1.07
|
| 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 Foundation Hospitals Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 2502100102
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.20
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.52
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 2502100102
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.32
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 5976203332
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.77
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
LEFLUNOMIDE 10 MG TABLET [23872]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 7071011573
|
| 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 Non-Gatekeeper |
$0.81
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.66
|
| 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 |
$0.59
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 6050525021
|
| 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 Non-Gatekeeper |
$1.98
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$1.60
|
| 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 |
$1.44
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$1.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 7071011573
|
| 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: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: Cash Price |
$0.59
|
| 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 Foundation Hospitals 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 6050525021
|
| 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: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Cash Price |
$1.44
|
| 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 Foundation Hospitals 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
|
$3.32
|
|
|
Service Code
|
NDC 6050525031
|
| 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: Aetna of CA Non-Gatekeeper |
$2.14
|
| Rate for Payer: Cash Price |
$1.49
|
| 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 Foundation Hospitals 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
|
$1.31
|
|
|
Service Code
|
NDC 6233206230
|
| 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 Non-Gatekeeper |
$0.81
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.66
|
| 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 |
$0.59
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 6233206230
|
| 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: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: Cash Price |
$0.59
|
| 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 Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
|
OP
|
$3.32
|
|
|
Service Code
|
NDC 6050525031
|
| 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 Non-Gatekeeper |
$2.05
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$1.66
|
| 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 |
$1.49
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$1.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 2315504403
|
| 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 Non-Gatekeeper |
$0.54
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| 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 |
$0.40
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 2315504403
|
| 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: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: Cash Price |
$0.40
|
| 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 Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
|
|
LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$10,001.00
|
|
|
Service Code
|
CPT 27685
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,208.34 |
| Max. Negotiated Rate |
$10,001.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,208.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,629.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,208.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,208.34
|
| Rate for Payer: Heritage Provider Network Senior |
$5,176.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,995.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,839.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,639.18
|
| Rate for Payer: Multiplan WC |
$6,568.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,629.17
|
| Rate for Payer: TriValley Medical Group Senior |
$4,629.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,001.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,445.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4,208.34
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
OP
|
$19.44
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$16.52 |
| Rate for Payer: Adventist Health Commercial |
$3.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.58
|
| Rate for Payer: Blue Shield of California Commercial |
$11.86
|
| Rate for Payer: Blue Shield of California EPN |
$9.49
|
| Rate for Payer: Cash Price |
$8.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.00
|
| Rate for Payer: Heritage Provider Network Senior |
$9.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$9.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13.61
|
| Rate for Payer: Multiplan Commercial |
$14.58
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.78
|
| Rate for Payer: TriValley Medical Group Senior |
$7.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.52
|
| Rate for Payer: Vantage Medical Group Senior |
$16.52
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
|
IP
|
$19.44
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$14.58 |
| Rate for Payer: Adventist Health Commercial |
$3.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.52
|
| Rate for Payer: Cash Price |
$8.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.00
|
| Rate for Payer: Heritage Provider Network Senior |
$9.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.86
|
| Rate for Payer: Multiplan Commercial |
$14.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.44
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
OP
|
$337.50
|
|
|
Service Code
|
NDC 0006307604
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$61.09 |
| Max. Negotiated Rate |
$286.88 |
| Rate for Payer: Adventist Health Commercial |
$67.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$208.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$286.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$185.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$253.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$168.82
|
| Rate for Payer: Blue Shield of California Commercial |
$205.88
|
| Rate for Payer: Blue Shield of California EPN |
$164.70
|
| Rate for Payer: Cash Price |
$151.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$219.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$286.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$286.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$286.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$216.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$208.91
|
| Rate for Payer: Heritage Provider Network Senior |
$208.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$160.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$61.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$236.25
|
| Rate for Payer: Multiplan Commercial |
$253.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$135.00
|
| Rate for Payer: TriValley Medical Group Senior |
$135.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$168.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$168.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$286.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$286.88
|
| Rate for Payer: Vantage Medical Group Senior |
$286.88
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
IP
|
$337.50
|
|
|
Service Code
|
NDC 0006307603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$61.09 |
| Max. Negotiated Rate |
$253.12 |
| Rate for Payer: Adventist Health Commercial |
$67.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$217.35
|
| Rate for Payer: Cash Price |
$151.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$182.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$228.49
|
| Rate for Payer: Heritage Provider Network Senior |
$228.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$61.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.38
|
| Rate for Payer: Multiplan Commercial |
$253.12
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
OP
|
$337.50
|
|
|
Service Code
|
NDC 0006307603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$61.09 |
| Max. Negotiated Rate |
$286.88 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$286.88
|
| Rate for Payer: Adventist Health Commercial |
$67.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$208.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$286.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$185.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$253.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$168.82
|
| Rate for Payer: Blue Shield of California Commercial |
$205.88
|
| Rate for Payer: Blue Shield of California EPN |
$164.70
|
| Rate for Payer: Cash Price |
$151.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$219.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$286.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$286.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$286.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$216.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$208.91
|
| Rate for Payer: Heritage Provider Network Senior |
$208.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$160.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$61.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$236.25
|
| Rate for Payer: Multiplan Commercial |
$253.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$135.00
|
| Rate for Payer: TriValley Medical Group Senior |
$135.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$168.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$168.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$286.88
|
| Rate for Payer: Vantage Medical Group Senior |
$286.88
|
|
|
LETERMOVIR 480 MG TABLET [220339]
|
Facility
|
IP
|
$337.50
|
|
|
Service Code
|
NDC 0006307604
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$61.09 |
| Max. Negotiated Rate |
$253.12 |
| Rate for Payer: Adventist Health Commercial |
$67.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$217.35
|
| Rate for Payer: Cash Price |
$151.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$182.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$228.49
|
| Rate for Payer: Heritage Provider Network Senior |
$228.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$61.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.38
|
| Rate for Payer: Multiplan Commercial |
$253.12
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 1672903410
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 5026847615
|
| 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: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.30
|
| 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 Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
