|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC
|
Facility
|
IP
|
$57,080.73
|
|
|
Service Code
|
MSDRG 492
|
| Min. Negotiated Rate |
$3,928.00 |
| Max. Negotiated Rate |
$57,080.73 |
| Rate for Payer: EPIC Health Plan Medicare |
$42,597.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,319.00
|
| Rate for Payer: Heritage Provider Network Senior |
$3,928.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$42,597.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$48,987.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$57,080.73
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC
|
Facility
|
IP
|
$31,512.34
|
|
|
Service Code
|
MSDRG 494
|
| Min. Negotiated Rate |
$3,928.00 |
| Max. Negotiated Rate |
$31,512.34 |
| Rate for Payer: EPIC Health Plan Medicare |
$23,516.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,319.00
|
| Rate for Payer: Heritage Provider Network Senior |
$3,928.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$23,516.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27,044.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$31,512.34
|
|
|
LOXAPINE SUCCINATE 10 MG CAPSULE [4599]
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
NDC 0591037001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
LOXAPINE SUCCINATE 10 MG CAPSULE [4599]
|
Facility
|
IP
|
$0.86
|
|
|
Service Code
|
NDC 0527139501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
LOXAPINE SUCCINATE 10 MG CAPSULE [4599]
|
Facility
|
IP
|
$0.86
|
|
|
Service Code
|
NDC 0591037001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
LOXAPINE SUCCINATE 10 MG CAPSULE [4599]
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
NDC 0527139501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
LUBIPROSTONE 24 MCG CAPSULE [70472]
|
Facility
|
IP
|
$2.12
|
|
|
Service Code
|
NDC 0480413806
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
LUBIPROSTONE 24 MCG CAPSULE [70472]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 0254302902
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
LUBIPROSTONE 24 MCG CAPSULE [70472]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 0254302902
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.77
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
LUBIPROSTONE 24 MCG CAPSULE [70472]
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 0480413806
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.06
|
| Rate for Payer: Blue Shield of California Commercial |
$1.29
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| 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 |
$1.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Senior |
$0.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1.80
|
|
|
LUBIPROSTONE 8 MCG CAPSULE [91534]
|
Facility
|
IP
|
$7.42
|
|
|
Service Code
|
NDC 6476408060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$5.57 |
| Rate for Payer: Adventist Health Commercial |
$1.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.78
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.02
|
| Rate for Payer: Heritage Provider Network Senior |
$5.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$5.57
|
|
|
LUBIPROSTONE 8 MCG CAPSULE [91534]
|
Facility
|
OP
|
$7.42
|
|
|
Service Code
|
NDC 6476408060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$6.31 |
| Rate for Payer: Adventist Health Commercial |
$1.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.71
|
| Rate for Payer: Blue Shield of California Commercial |
$4.53
|
| Rate for Payer: Blue Shield of California EPN |
$3.62
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.59
|
| Rate for Payer: Heritage Provider Network Senior |
$4.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.19
|
| Rate for Payer: Multiplan Commercial |
$5.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.97
|
| Rate for Payer: TriValley Medical Group Senior |
$2.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.31
|
| Rate for Payer: Vantage Medical Group Senior |
$6.31
|
|
|
LUBIPROSTONE 8 MCG CAPSULE [91534]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 0254302802
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.77
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
LUBIPROSTONE 8 MCG CAPSULE [91534]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 0254302802
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
LUNG TRANSPLANT
|
Facility
|
IP
|
$199,557.95
|
|
|
Service Code
|
MSDRG 007
|
| Min. Negotiated Rate |
$148,923.84 |
| Max. Negotiated Rate |
$199,557.95 |
| Rate for Payer: EPIC Health Plan Medicare |
$148,923.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$148,923.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$171,262.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$199,557.95
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 4733557883
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 4733557883
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 6068774721
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.29
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.46
|
| Rate for Payer: Heritage Provider Network Senior |
$3.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 6068774721
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.34
|
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.56
|
| Rate for Payer: Blue Shield of California Commercial |
$3.12
|
| Rate for Payer: Blue Shield of California EPN |
$2.49
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.16
|
| Rate for Payer: Heritage Provider Network Senior |
$3.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.04
|
| Rate for Payer: TriValley Medical Group Senior |
$2.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: Vantage Medical Group Senior |
$4.34
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 6068774711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.29
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.46
|
| Rate for Payer: Heritage Provider Network Senior |
$3.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
|
|
LURASIDONE 20 MG TABLET [154462]
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 6068774711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.56
|
| Rate for Payer: Blue Shield of California Commercial |
$3.12
|
| Rate for Payer: Blue Shield of California EPN |
$2.49
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.16
|
| Rate for Payer: Heritage Provider Network Senior |
$3.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.04
|
| Rate for Payer: TriValley Medical Group Senior |
$2.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.34
|
| Rate for Payer: Vantage Medical Group Senior |
$4.34
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$58.45
|
|
|
Service Code
|
NDC 6340230430
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.58 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Adventist Health Commercial |
$11.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$49.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$43.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$29.24
|
| Rate for Payer: Blue Shield of California Commercial |
$35.65
|
| Rate for Payer: Blue Shield of California EPN |
$28.52
|
| Rate for Payer: Cash Price |
$26.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$49.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$49.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.18
|
| Rate for Payer: Heritage Provider Network Senior |
$36.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$27.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$40.91
|
| Rate for Payer: Multiplan Commercial |
$43.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$23.38
|
| Rate for Payer: TriValley Medical Group Senior |
$23.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$49.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$49.68
|
| Rate for Payer: Vantage Medical Group Senior |
$49.68
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 6068775821
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.30
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Senior |
$3.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 4733568483
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 4733568483
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
