|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]
|
Facility
|
OP
|
$103.43
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$87.92 |
| Rate for Payer: Adventist Health Commercial |
$20.69
|
| Rate for Payer: Adventist Health Commercial |
$21.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$63.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$87.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$56.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$77.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$79.20
|
| 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 |
$46.54
|
| Rate for Payer: Cash Price |
$47.52
|
| 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: Dignity Health Commercial/Exchange |
$87.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$87.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$87.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$89.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.89
|
| Rate for Payer: Heritage Provider Network Senior |
$48.89
|
| Rate for Payer: Heritage Provider Network Senior |
$47.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$49.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$50.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$73.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$72.40
|
| Rate for Payer: Multiplan Commercial |
$79.20
|
| Rate for Payer: Multiplan Commercial |
$77.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$41.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$42.24
|
| Rate for Payer: TriValley Medical Group Senior |
$41.37
|
| Rate for Payer: TriValley Medical Group Senior |
$42.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$38.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$87.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$87.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.76
|
| Rate for Payer: Vantage Medical Group Senior |
$89.76
|
| Rate for Payer: Vantage Medical Group Senior |
$87.92
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
|
IP
|
$6.34
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Adventist Health Commercial |
$1.27
|
| Rate for Payer: Adventist Health Commercial |
$2.11
|
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.80
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.56
|
| Rate for Payer: Heritage Provider Network Senior |
$5.56
|
| Rate for Payer: Heritage Provider Network Senior |
$4.89
|
| Rate for Payer: Heritage Provider Network Senior |
$2.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$4.75
|
| Rate for Payer: Multiplan Commercial |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.97
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
|
OP
|
$10.56
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$48.71 |
| Rate for Payer: Adventist Health Commercial |
$2.11
|
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Adventist Health Commercial |
$1.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.00
|
| 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: 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 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 |
$5.40
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Senior |
$5.56
|
| Rate for Payer: Heritage Provider Network Senior |
$4.89
|
| Rate for Payer: Heritage Provider Network Senior |
$2.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$4.75
|
| Rate for Payer: Multiplan Commercial |
$7.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.54
|
| Rate for Payer: TriValley Medical Group Senior |
$2.54
|
| Rate for Payer: TriValley Medical Group Senior |
$4.80
|
| Rate for Payer: TriValley Medical Group Senior |
$4.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.20
|
| Rate for Payer: Vantage Medical Group Senior |
$8.98
|
| Rate for Payer: Vantage Medical Group Senior |
$5.39
|
| Rate for Payer: Vantage Medical Group Senior |
$10.20
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 6931518401
|
| 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
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 5074218130
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 6931518401
|
| 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
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 0054449613
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Senior |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 6931518403
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.89
|
|
|
Service Code
|
NDC 0054849619
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.22
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 0054449613
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 0054849619
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.95
|
| Rate for Payer: Blue Shield of California Commercial |
$1.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.17
|
| Rate for Payer: Heritage Provider Network Senior |
$1.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Senior |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.61
|
| Rate for Payer: Vantage Medical Group Senior |
$1.61
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 6931518403
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Senior |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 5074218130
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
LEUPROLIDE 11.25 MG INTRAMUSCULAR KIT [10390]
|
Facility
|
OP
|
$4,956.43
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$897.11 |
| Max. Negotiated Rate |
$3,717.32 |
| Rate for Payer: Adventist Health Commercial |
$991.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,063.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,301.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,025.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,025.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,089.01
|
| Rate for Payer: Blue Shield of California Commercial |
$1,749.65
|
| Rate for Payer: Blue Shield of California EPN |
$1,749.65
|
| Rate for Payer: Cash Price |
$2,230.39
|
| Rate for Payer: Cash Price |
$2,230.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,279.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,301.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,025.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,025.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,172.12
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,841.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,294.83
|
| Rate for Payer: Heritage Provider Network Senior |
$2,294.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,841.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,364.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$897.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,117.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,239.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,467.29
|
| Rate for Payer: Multiplan Commercial |
$3,717.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,982.57
|
| Rate for Payer: TriValley Medical Group Senior |
$1,982.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,790.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,641.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,301.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,025.39
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.39
|
|
|
LEUPROLIDE 11.25 MG INTRAMUSCULAR KIT [10390]
|
Facility
|
IP
|
$4,956.43
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$897.11 |
| Max. Negotiated Rate |
$3,717.32 |
| Rate for Payer: Adventist Health Commercial |
$991.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,191.94
|
| Rate for Payer: Cash Price |
$2,230.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,279.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,676.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,294.83
|
| Rate for Payer: Heritage Provider Network Senior |
$2,294.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$897.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,239.11
|
| Rate for Payer: Multiplan Commercial |
$3,717.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,790.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,641.07
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT [14135]
|
Facility
|
IP
|
$855.36
|
|
|
Service Code
|
HCPCS J9218
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.82 |
| Max. Negotiated Rate |
$641.52 |
| Rate for Payer: Adventist Health Commercial |
$171.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$550.85
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$393.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$461.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$396.03
|
| Rate for Payer: Heritage Provider Network Senior |
$396.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$154.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.84
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$309.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$283.21
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT [14135]
|
Facility
|
OP
|
$855.36
|
|
|
Service Code
|
HCPCS J9218
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.73 |
| Max. Negotiated Rate |
$727.06 |
| Rate for Payer: Adventist Health Commercial |
$171.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$528.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$727.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$470.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$641.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$208.82
|
| Rate for Payer: Blue Shield of California Commercial |
$51.73
|
| Rate for Payer: Blue Shield of California EPN |
$51.73
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$393.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$727.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$727.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$727.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$547.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$396.03
|
| Rate for Payer: Heritage Provider Network Senior |
$396.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$408.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$154.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$598.75
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$342.14
|
| Rate for Payer: TriValley Medical Group Senior |
$342.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$309.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$283.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$727.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$727.06
|
| Rate for Payer: Vantage Medical Group Senior |
$727.06
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT. [40814135]
|
Facility
|
IP
|
$855.36
|
|
|
Service Code
|
HCPCS J9218
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.82 |
| Max. Negotiated Rate |
$641.52 |
| Rate for Payer: EPIC Health Plan Commercial |
$461.89
|
| Rate for Payer: Adventist Health Commercial |
$171.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$550.85
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$393.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$396.03
|
| Rate for Payer: Heritage Provider Network Senior |
$396.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$154.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.84
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$309.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$283.21
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT. [40814135]
|
Facility
|
OP
|
$855.36
|
|
|
Service Code
|
HCPCS J9218
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.73 |
| Max. Negotiated Rate |
$727.06 |
| Rate for Payer: Adventist Health Commercial |
$171.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$528.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$727.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$470.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$641.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$208.82
|
| Rate for Payer: Blue Shield of California Commercial |
$51.73
|
| Rate for Payer: Blue Shield of California EPN |
$51.73
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$393.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$727.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$727.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$727.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$547.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$396.03
|
| Rate for Payer: Heritage Provider Network Senior |
$396.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$408.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$154.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$598.75
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$342.14
|
| Rate for Payer: TriValley Medical Group Senior |
$342.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$309.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$283.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$727.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$727.06
|
| Rate for Payer: Vantage Medical Group Senior |
$727.06
|
|
|
LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT [21108]
|
Facility
|
IP
|
$10,817.35
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,957.94 |
| Max. Negotiated Rate |
$8,113.01 |
| Rate for Payer: Adventist Health Commercial |
$2,163.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,966.37
|
| Rate for Payer: Cash Price |
$4,867.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,975.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,841.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,008.43
|
| Rate for Payer: Heritage Provider Network Senior |
$5,008.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,957.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,704.34
|
| Rate for Payer: Multiplan Commercial |
$8,113.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,908.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,581.62
|
|
|
LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT [21108]
|
Facility
|
OP
|
$10,817.35
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.34 |
| Max. Negotiated Rate |
$8,113.01 |
| Rate for Payer: Adventist Health Commercial |
$2,163.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,685.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$240.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$176.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$160.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,300.50
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$4,867.81
|
| Rate for Payer: Cash Price |
$4,867.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,975.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$200.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$176.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$176.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,923.10
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,008.43
|
| Rate for Payer: Heritage Provider Network Senior |
$5,008.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,159.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,957.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,704.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.86
|
| Rate for Payer: Multiplan Commercial |
$8,113.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,326.94
|
| Rate for Payer: TriValley Medical Group Senior |
$4,326.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,908.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,581.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$200.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$176.37
|
| Rate for Payer: Vantage Medical Group Senior |
$176.37
|
|
|
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [13691]
|
Facility
|
IP
|
$2,269.40
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$410.76 |
| Max. Negotiated Rate |
$1,702.05 |
| Rate for Payer: Adventist Health Commercial |
$453.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,461.49
|
| Rate for Payer: Cash Price |
$1,021.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,043.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,225.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,050.73
|
| Rate for Payer: Heritage Provider Network Senior |
$1,050.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$410.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$567.35
|
| Rate for Payer: Multiplan Commercial |
$1,702.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$819.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$751.40
|
|
|
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [13691]
|
Facility
|
OP
|
$2,269.40
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$410.76 |
| Max. Negotiated Rate |
$2,467.29 |
| Rate for Payer: Adventist Health Commercial |
$453.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,402.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,301.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,025.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,025.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,089.01
|
| Rate for Payer: Blue Shield of California Commercial |
$1,749.65
|
| Rate for Payer: Blue Shield of California EPN |
$1,749.65
|
| Rate for Payer: Cash Price |
$1,021.23
|
| Rate for Payer: Cash Price |
$1,021.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,043.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,301.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,025.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,025.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,452.42
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,841.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,050.73
|
| Rate for Payer: Heritage Provider Network Senior |
$1,050.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,841.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,082.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$410.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,117.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$567.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,467.29
|
| Rate for Payer: Multiplan Commercial |
$1,702.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$907.76
|
| Rate for Payer: TriValley Medical Group Senior |
$907.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$819.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$751.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,301.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,025.39
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.39
|
|
|
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]
|
Facility
|
IP
|
$542.03
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.11 |
| Max. Negotiated Rate |
$406.52 |
| Rate for Payer: Adventist Health Commercial |
$108.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$349.07
|
| Rate for Payer: Cash Price |
$243.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$249.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$292.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$250.96
|
| Rate for Payer: Heritage Provider Network Senior |
$250.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$98.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.51
|
| Rate for Payer: Multiplan Commercial |
$406.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$195.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$179.47
|
|
|
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]
|
Facility
|
OP
|
$542.03
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.11 |
| Max. Negotiated Rate |
$1,300.50 |
| Rate for Payer: Adventist Health Commercial |
$108.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$334.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$240.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$176.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$160.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,300.50
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$243.91
|
| Rate for Payer: Cash Price |
$243.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$249.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$200.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$176.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$176.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$346.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$250.96
|
| Rate for Payer: Heritage Provider Network Senior |
$250.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$258.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$98.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.86
|
| Rate for Payer: Multiplan Commercial |
$406.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$216.81
|
| Rate for Payer: TriValley Medical Group Senior |
$216.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$195.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$179.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$200.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$176.37
|
| Rate for Payer: Vantage Medical Group Senior |
$176.37
|
|
