|
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
|
|
|
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
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 5026847615
|
| 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 Non-Gatekeeper |
$0.41
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| 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 |
$0.30
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 5026847611
|
| 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 Non-Gatekeeper |
$0.41
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| 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 |
$0.30
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]
|
Facility
|
IP
|
$19.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$14.40 |
| Rate for Payer: Adventist Health Commercial |
$3.84
|
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.46
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.11
|
| Rate for Payer: Heritage Provider Network Senior |
$11.11
|
| Rate for Payer: Heritage Provider Network Senior |
$8.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.36
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]
|
Facility
|
OP
|
$19.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$48.71 |
| Rate for Payer: Adventist Health Commercial |
$3.84
|
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.71
|
| Rate for Payer: Blue Shield of California Commercial |
$8.41
|
| Rate for Payer: Blue Shield of California Commercial |
$8.41
|
| Rate for Payer: Blue Shield of California EPN |
$8.41
|
| Rate for Payer: Blue Shield of California EPN |
$8.41
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.89
|
| Rate for Payer: Heritage Provider Network Senior |
$11.11
|
| Rate for Payer: Heritage Provider Network Senior |
$8.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$9.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13.44
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.60
|
| Rate for Payer: TriValley Medical Group Senior |
$7.68
|
| Rate for Payer: TriValley Medical Group Senior |
$9.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$16.32
|
|
|
LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [15370]
|
Facility
|
IP
|
$2.84
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.83
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.94
|
|
|
LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [15370]
|
Facility
|
OP
|
$2.84
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$48.71 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.71
|
| Rate for Payer: Blue Shield of California Commercial |
$8.41
|
| Rate for Payer: Blue Shield of California EPN |
$8.41
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.99
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.14
|
| Rate for Payer: TriValley Medical Group Senior |
$1.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.41
|
| Rate for Payer: Vantage Medical Group Senior |
$2.41
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 5074218212
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.54
|
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.55
|
| Rate for Payer: Heritage Provider Network Senior |
$1.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Senior |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$7.48
|
|
|
Service Code
|
NDC 0054449705
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$5.61 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.82
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.06
|
| Rate for Payer: Heritage Provider Network Senior |
$5.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.87
|
| Rate for Payer: Multiplan Commercial |
$5.61
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$7.48
|
|
|
Service Code
|
NDC 0054449705
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$6.36 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.74
|
| Rate for Payer: Blue Shield of California Commercial |
$4.56
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.63
|
| Rate for Payer: Heritage Provider Network Senior |
$4.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$5.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.99
|
| Rate for Payer: TriValley Medical Group Senior |
$2.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: Vantage Medical Group Senior |
$6.36
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$6.65
|
|
|
Service Code
|
NDC 0054449710
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$4.99 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.28
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.50
|
| Rate for Payer: Heritage Provider Network Senior |
$4.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.66
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$7.48
|
|
|
Service Code
|
NDC 6931518512
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$5.61 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.82
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.06
|
| Rate for Payer: Heritage Provider Network Senior |
$5.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.87
|
| Rate for Payer: Multiplan Commercial |
$5.61
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$6.65
|
|
|
Service Code
|
NDC 0054449710
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.65 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.33
|
| Rate for Payer: Blue Shield of California Commercial |
$4.06
|
| Rate for Payer: Blue Shield of California EPN |
$3.25
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.12
|
| Rate for Payer: Heritage Provider Network Senior |
$4.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.66
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.66
|
| Rate for Payer: TriValley Medical Group Senior |
$2.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.65
|
| Rate for Payer: Vantage Medical Group Senior |
$5.65
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 5074218212
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.69
|
| Rate for Payer: Heritage Provider Network Senior |
$1.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 5074218224
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.69
|
| Rate for Payer: Heritage Provider Network Senior |
$1.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 5074218224
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.55
|
| Rate for Payer: Heritage Provider Network Senior |
$1.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Senior |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$7.48
|
|
|
Service Code
|
NDC 6931518512
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$6.36 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.74
|
| Rate for Payer: Blue Shield of California Commercial |
$4.56
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.63
|
| Rate for Payer: Heritage Provider Network Senior |
$4.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$5.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.99
|
| Rate for Payer: TriValley Medical Group Senior |
$2.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: Vantage Medical Group Senior |
$6.36
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
IP
|
$6.65
|
|
|
Service Code
|
NDC 6931518524
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$4.99 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.28
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.50
|
| Rate for Payer: Heritage Provider Network Senior |
$4.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.66
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
|
OP
|
$6.65
|
|
|
Service Code
|
NDC 6931518524
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.65 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.33
|
| Rate for Payer: Blue Shield of California Commercial |
$4.06
|
| Rate for Payer: Blue Shield of California EPN |
$3.25
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.12
|
| Rate for Payer: Heritage Provider Network Senior |
$4.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.66
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.66
|
| Rate for Payer: TriValley Medical Group Senior |
$2.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.65
|
| Rate for Payer: Vantage Medical Group Senior |
$5.65
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]
|
Facility
|
OP
|
$28.80
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.21 |
| Max. Negotiated Rate |
$48.71 |
| Rate for Payer: Adventist Health Commercial |
$5.76
|
| Rate for Payer: Adventist Health Commercial |
$5.53
|
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.71
|
| Rate for Payer: Blue Shield of California Commercial |
$8.41
|
| Rate for Payer: Blue Shield of California Commercial |
$8.41
|
| Rate for Payer: Blue Shield of California Commercial |
$8.41
|
| Rate for Payer: Blue Shield of California Commercial |
$8.41
|
| Rate for Payer: Blue Shield of California EPN |
$8.41
|
| Rate for Payer: Blue Shield of California EPN |
$8.41
|
| Rate for Payer: Blue Shield of California EPN |
$8.41
|
| Rate for Payer: Blue Shield of California EPN |
$8.41
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$23.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$40.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.11
|
| Rate for Payer: Heritage Provider Network Senior |
$13.33
|
| Rate for Payer: Heritage Provider Network Senior |
$12.81
|
| Rate for Payer: Heritage Provider Network Senior |
$22.22
|
| Rate for Payer: Heritage Provider Network Senior |
$11.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$13.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$22.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$13.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$19.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$33.60
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: Multiplan Commercial |
$20.75
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.07
|
| Rate for Payer: TriValley Medical Group Senior |
$11.07
|
| Rate for Payer: TriValley Medical Group Senior |
$19.20
|
| Rate for Payer: TriValley Medical Group Senior |
$11.52
|
| Rate for Payer: TriValley Medical Group Senior |
$9.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$24.48
|
| Rate for Payer: Vantage Medical Group Senior |
$23.52
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$20.40
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]
|
Facility
|
IP
|
$28.80
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.21 |
| Max. Negotiated Rate |
$21.60 |
| Rate for Payer: Adventist Health Commercial |
$5.76
|
| Rate for Payer: Adventist Health Commercial |
$5.53
|
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.91
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.33
|
| Rate for Payer: Heritage Provider Network Senior |
$13.33
|
| Rate for Payer: Heritage Provider Network Senior |
$11.11
|
| Rate for Payer: Heritage Provider Network Senior |
$12.81
|
| Rate for Payer: Heritage Provider Network Senior |
$22.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: Multiplan Commercial |
$20.75
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.89
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]
|
Facility
|
OP
|
$31.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$48.71 |
| Rate for Payer: Adventist Health Commercial |
$6.24
|
| Rate for Payer: Adventist Health Commercial |
$4.55
|
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Adventist Health Commercial |
$4.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$63.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$23.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.71
|
| Rate for Payer: Blue Shield of California Commercial |
$8.41
|
| Rate for Payer: Blue Shield of California Commercial |
$8.41
|
| Rate for Payer: Blue Shield of California Commercial |
$8.41
|
| Rate for Payer: Blue Shield of California Commercial |
$8.41
|
| Rate for Payer: Blue Shield of California EPN |
$8.41
|
| Rate for Payer: Blue Shield of California EPN |
$8.41
|
| Rate for Payer: Blue Shield of California EPN |
$8.41
|
| Rate for Payer: Blue Shield of California EPN |
$8.41
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$26.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$19.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$71.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$17.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.78
|
| Rate for Payer: Heritage Provider Network Senior |
$14.45
|
| Rate for Payer: Heritage Provider Network Senior |
$10.53
|
| Rate for Payer: Heritage Provider Network Senior |
$38.89
|
| Rate for Payer: Heritage Provider Network Senior |
$9.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$40.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$10.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$10.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$14.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$58.80
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$23.40
|
| Rate for Payer: Multiplan Commercial |
$17.05
|
| Rate for Payer: Multiplan Commercial |
$15.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$33.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.10
|
| Rate for Payer: TriValley Medical Group Senior |
$9.10
|
| Rate for Payer: TriValley Medical Group Senior |
$33.60
|
| Rate for Payer: TriValley Medical Group Senior |
$12.48
|
| Rate for Payer: TriValley Medical Group Senior |
$8.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.95
|
| Rate for Payer: Vantage Medical Group Senior |
$26.52
|
| Rate for Payer: Vantage Medical Group Senior |
$19.33
|
| Rate for Payer: Vantage Medical Group Senior |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$17.95
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]
|
Facility
|
IP
|
$31.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$23.40 |
| Rate for Payer: Adventist Health Commercial |
$6.24
|
| Rate for Payer: Adventist Health Commercial |
$4.55
|
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Adventist Health Commercial |
$4.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.10
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.45
|
| Rate for Payer: Heritage Provider Network Senior |
$14.45
|
| Rate for Payer: Heritage Provider Network Senior |
$9.78
|
| Rate for Payer: Heritage Provider Network Senior |
$10.53
|
| Rate for Payer: Heritage Provider Network Senior |
$38.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.28
|
| Rate for Payer: Multiplan Commercial |
$15.84
|
| Rate for Payer: Multiplan Commercial |
$23.40
|
| Rate for Payer: Multiplan Commercial |
$17.05
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.81
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]
|
Facility
|
IP
|
$103.43
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.72 |
| Max. Negotiated Rate |
$77.57 |
| Rate for Payer: Adventist Health Commercial |
$20.69
|
| Rate for Payer: Adventist Health Commercial |
$21.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$66.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$68.01
|
| Rate for Payer: Cash Price |
$46.54
|
| Rate for Payer: Cash Price |
$47.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$47.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.89
|
| Rate for Payer: Heritage Provider Network Senior |
$48.89
|
| Rate for Payer: Heritage Provider Network Senior |
$47.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.40
|
| Rate for Payer: Multiplan Commercial |
$77.57
|
| Rate for Payer: Multiplan Commercial |
$79.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$38.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.25
|
|
