|
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
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 6068775811
|
| 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
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 6068775821
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.57
|
| Rate for Payer: Blue Shield of California Commercial |
$3.13
|
| Rate for Payer: Blue Shield of California EPN |
$2.50
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.18
|
| Rate for Payer: Heritage Provider Network Senior |
$3.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.59
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.05
|
| Rate for Payer: TriValley Medical Group Senior |
$2.05
|
| 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 |
$4.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.36
|
| Rate for Payer: Vantage Medical Group Senior |
$4.36
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$58.45
|
|
|
Service Code
|
NDC 6340230430
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.58 |
| Max. Negotiated Rate |
$43.84 |
| Rate for Payer: Adventist Health Commercial |
$11.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.64
|
| Rate for Payer: Cash Price |
$26.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.57
|
| Rate for Payer: Heritage Provider Network Senior |
$39.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.61
|
| Rate for Payer: Multiplan Commercial |
$43.84
|
|
|
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [228261]
|
Facility
|
IP
|
$10,092.00
|
|
|
Service Code
|
HCPCS J9223
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,826.65 |
| Max. Negotiated Rate |
$7,569.00 |
| Rate for Payer: Adventist Health Commercial |
$2,018.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,499.25
|
| Rate for Payer: Cash Price |
$4,541.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,642.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,449.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,672.60
|
| Rate for Payer: Heritage Provider Network Senior |
$4,672.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,826.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,523.00
|
| Rate for Payer: Multiplan Commercial |
$7,569.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,646.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,341.46
|
|
|
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [228261]
|
Facility
|
OP
|
$10,092.00
|
|
|
Service Code
|
HCPCS J9223
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$204.76 |
| Max. Negotiated Rate |
$7,569.00 |
| Rate for Payer: Adventist Health Commercial |
$2,018.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,236.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$323.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$237.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$215.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$401.92
|
| Rate for Payer: Blue Shield of California Commercial |
$204.76
|
| Rate for Payer: Blue Shield of California EPN |
$204.76
|
| Rate for Payer: Cash Price |
$4,541.40
|
| Rate for Payer: Cash Price |
$4,541.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,642.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$269.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$237.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$237.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,458.88
|
| Rate for Payer: EPIC Health Plan Medicare |
$215.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,672.60
|
| Rate for Payer: Heritage Provider Network Senior |
$4,672.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$215.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4,813.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,826.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$248.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,523.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$289.37
|
| Rate for Payer: Multiplan Commercial |
$7,569.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,036.80
|
| Rate for Payer: TriValley Medical Group Senior |
$4,036.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,646.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,341.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$269.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$237.54
|
| Rate for Payer: Vantage Medical Group Senior |
$237.54
|
|
|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [225877]
|
Facility
|
OP
|
$5,034.48
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.32 |
| Max. Negotiated Rate |
$3,775.86 |
| Rate for Payer: Adventist Health Commercial |
$1,006.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,111.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$47.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$84.67
|
| Rate for Payer: Blue Shield of California Commercial |
$40.32
|
| Rate for Payer: Blue Shield of California EPN |
$40.32
|
| Rate for Payer: Cash Price |
$2,265.52
|
| Rate for Payer: Cash Price |
$2,265.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,315.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$47.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,222.07
|
| Rate for Payer: EPIC Health Plan Medicare |
$43.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,330.96
|
| Rate for Payer: Heritage Provider Network Senior |
$2,330.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.51
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,401.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$911.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$50.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,258.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$58.30
|
| Rate for Payer: Multiplan Commercial |
$3,775.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,013.79
|
| Rate for Payer: TriValley Medical Group Senior |
$2,013.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,818.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,666.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.86
|
| Rate for Payer: Vantage Medical Group Senior |
$47.86
|
|
|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [225877]
|
Facility
|
IP
|
$5,034.48
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$911.24 |
| Max. Negotiated Rate |
$3,775.86 |
| Rate for Payer: Adventist Health Commercial |
$1,006.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,242.21
|
| Rate for Payer: Cash Price |
$2,265.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,315.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,718.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,330.96
|
| Rate for Payer: Heritage Provider Network Senior |
$2,330.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$911.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,258.62
|
| Rate for Payer: Multiplan Commercial |
$3,775.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,818.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,666.92
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [225879]
|
Facility
|
IP
|
$15,103.39
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,733.71 |
| Max. Negotiated Rate |
$11,327.54 |
| Rate for Payer: Adventist Health Commercial |
$3,020.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9,726.58
|
| Rate for Payer: Cash Price |
$6,796.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6,947.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,155.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,992.87
|
| Rate for Payer: Heritage Provider Network Senior |
$6,992.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,733.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,775.85
|
| Rate for Payer: Multiplan Commercial |
$11,327.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5,456.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5,000.73
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [225879]
|
Facility
|
OP
|
$15,103.39
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.32 |
| Max. Negotiated Rate |
$11,327.54 |
| Rate for Payer: Adventist Health Commercial |
$3,020.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9,333.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$47.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$84.67
|
| Rate for Payer: Blue Shield of California Commercial |
$40.32
|
| Rate for Payer: Blue Shield of California EPN |
$40.32
|
| Rate for Payer: Cash Price |
$6,796.53
|
| Rate for Payer: Cash Price |
$6,796.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6,947.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$47.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,666.17
|
| Rate for Payer: EPIC Health Plan Medicare |
$43.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,992.87
|
| Rate for Payer: Heritage Provider Network Senior |
$6,992.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.51
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,204.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,733.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$50.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,775.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$58.30
|
| Rate for Payer: Multiplan Commercial |
$11,327.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$6,041.36
|
| Rate for Payer: TriValley Medical Group Senior |
$6,041.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5,456.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5,000.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.86
|
| Rate for Payer: Vantage Medical Group Senior |
$47.86
|
|
|
LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [220890]
|
Facility
|
IP
|
$58,680.00
|
|
|
Service Code
|
HCPCS A9513
|
| Hospital Charge Code |
901700056
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$10,621.08 |
| Max. Negotiated Rate |
$44,010.00 |
| Rate for Payer: Adventist Health Commercial |
$11,736.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37,789.92
|
| Rate for Payer: Cash Price |
$26,406.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$31,687.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$39,726.36
|
| Rate for Payer: Heritage Provider Network Senior |
$39,726.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10,621.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14,670.00
|
| Rate for Payer: Multiplan Commercial |
$44,010.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21,201.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19,428.95
|
|
|
LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [220890]
|
Facility
|
OP
|
$58,680.00
|
|
|
Service Code
|
HCPCS A9513
|
| Hospital Charge Code |
901700056
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$350.21 |
| Max. Negotiated Rate |
$44,010.00 |
| Rate for Payer: Adventist Health Commercial |
$11,736.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36,264.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$437.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$385.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$385.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$575.74
|
| Rate for Payer: Blue Shield of California Commercial |
$35,794.80
|
| Rate for Payer: Blue Shield of California EPN |
$28,635.84
|
| Rate for Payer: Cash Price |
$26,406.00
|
| Rate for Payer: Cash Price |
$26,406.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38,142.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$437.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$385.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$385.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$37,555.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$350.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$36,322.92
|
| Rate for Payer: Heritage Provider Network Senior |
$36,322.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$350.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$27,990.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10,621.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$402.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14,670.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$469.28
|
| Rate for Payer: Multiplan Commercial |
$44,010.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$385.23
|
| Rate for Payer: TriValley Medical Group Senior |
$350.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21,201.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19,428.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$437.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$385.23
|
| Rate for Payer: Vantage Medical Group Senior |
$385.23
|
|
|
LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [233901]
|
Facility
|
IP
|
$52,020.00
|
|
|
Service Code
|
HCPCS A9607
|
| Hospital Charge Code |
901700056
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$9,415.62 |
| Max. Negotiated Rate |
$39,015.00 |
| Rate for Payer: Adventist Health Commercial |
$10,404.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33,500.88
|
| Rate for Payer: Cash Price |
$23,409.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$28,090.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$35,217.54
|
| Rate for Payer: Heritage Provider Network Senior |
$35,217.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9,415.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13,005.00
|
| Rate for Payer: Multiplan Commercial |
$39,015.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18,794.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17,223.82
|
|
|
LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [233901]
|
Facility
|
OP
|
$52,020.00
|
|
|
Service Code
|
HCPCS A9607
|
| Hospital Charge Code |
901700056
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$267.32 |
| Max. Negotiated Rate |
$39,015.00 |
| Rate for Payer: Adventist Health Commercial |
$10,404.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32,148.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$334.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$294.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$294.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$515.14
|
| Rate for Payer: Blue Shield of California Commercial |
$31,732.20
|
| Rate for Payer: Blue Shield of California EPN |
$25,385.76
|
| Rate for Payer: Cash Price |
$23,409.00
|
| Rate for Payer: Cash Price |
$23,409.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33,813.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$334.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$294.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$294.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$33,292.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$267.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$32,200.38
|
| Rate for Payer: Heritage Provider Network Senior |
$32,200.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$267.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$24,813.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9,415.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$307.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13,005.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$358.21
|
| Rate for Payer: Multiplan Commercial |
$39,015.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$294.05
|
| Rate for Payer: TriValley Medical Group Senior |
$267.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18,794.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17,223.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$334.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$294.05
|
| Rate for Payer: Vantage Medical Group Senior |
$294.05
|
|
|
LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION [10475]
|
Facility
|
IP
|
$1,339.22
|
|
|
Service Code
|
HCPCS J7504
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$242.40 |
| Max. Negotiated Rate |
$1,004.41 |
| Rate for Payer: Cigna of CA HMO/PPO |
$616.04
|
| Rate for Payer: Adventist Health Commercial |
$267.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$862.46
|
| Rate for Payer: Cash Price |
$602.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$723.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$620.06
|
| Rate for Payer: Heritage Provider Network Senior |
$620.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$242.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$334.81
|
| Rate for Payer: Multiplan Commercial |
$1,004.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$483.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$443.42
|
|
|
LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION [10475]
|
Facility
|
OP
|
$1,339.22
|
|
|
Service Code
|
HCPCS J7504
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$242.40 |
| Max. Negotiated Rate |
$8,323.44 |
| Rate for Payer: Adventist Health Commercial |
$267.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$827.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8,323.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6,103.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,548.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$617.33
|
| Rate for Payer: Blue Shield of California Commercial |
$4,275.39
|
| Rate for Payer: Blue Shield of California EPN |
$4,275.39
|
| Rate for Payer: Cash Price |
$602.65
|
| Rate for Payer: Cash Price |
$602.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$616.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,936.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$6,103.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6,103.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$857.10
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,548.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$620.06
|
| Rate for Payer: Heritage Provider Network Senior |
$620.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,548.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$638.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$242.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6,381.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$334.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7,435.61
|
| Rate for Payer: Multiplan Commercial |
$1,004.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$535.69
|
| Rate for Payer: TriValley Medical Group Senior |
$535.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$483.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$443.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,936.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6,103.86
|
| Rate for Payer: Vantage Medical Group Senior |
$6,103.86
|
|
|
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC
|
Facility
|
IP
|
$35,076.34
|
|
|
Service Code
|
MSDRG 821
|
| Min. Negotiated Rate |
$26,176.37 |
| Max. Negotiated Rate |
$35,076.34 |
| Rate for Payer: EPIC Health Plan Medicare |
$26,176.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$26,176.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$30,102.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$35,076.34
|
|
|
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC
|
Facility
|
IP
|
$90,758.35
|
|
|
Service Code
|
MSDRG 820
|
| Min. Negotiated Rate |
$67,730.11 |
| Max. Negotiated Rate |
$90,758.35 |
| Rate for Payer: EPIC Health Plan Medicare |
$67,730.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$67,730.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$77,889.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$90,758.35
|
|
|
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$19,189.56
|
|
|
Service Code
|
MSDRG 822
|
| Min. Negotiated Rate |
$14,320.57 |
| Max. Negotiated Rate |
$19,189.56 |
| Rate for Payer: EPIC Health Plan Medicare |
$14,320.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14,320.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16,468.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$19,189.56
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC
|
Facility
|
IP
|
$25,752.50
|
|
|
Service Code
|
MSDRG 841
|
| Min. Negotiated Rate |
$19,218.28 |
| Max. Negotiated Rate |
$25,752.50 |
| Rate for Payer: EPIC Health Plan Medicare |
$19,218.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19,218.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22,101.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25,752.50
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC
|
Facility
|
IP
|
$50,375.00
|
|
|
Service Code
|
MSDRG 840
|
| Min. Negotiated Rate |
$37,593.28 |
| Max. Negotiated Rate |
$50,375.00 |
| Rate for Payer: EPIC Health Plan Medicare |
$37,593.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37,593.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$43,232.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50,375.00
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC
|
Facility
|
IP
|
$35,490.95
|
|
|
Service Code
|
MSDRG 824
|
| Min. Negotiated Rate |
$26,485.78 |
| Max. Negotiated Rate |
$35,490.95 |
| Rate for Payer: EPIC Health Plan Medicare |
$26,485.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$26,485.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$30,458.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$35,490.95
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC
|
Facility
|
IP
|
$71,103.33
|
|
|
Service Code
|
MSDRG 823
|
| Min. Negotiated Rate |
$53,062.19 |
| Max. Negotiated Rate |
$71,103.33 |
| Rate for Payer: EPIC Health Plan Medicare |
$53,062.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$53,062.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$61,021.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$71,103.33
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$21,422.27
|
|
|
Service Code
|
MSDRG 825
|
| Min. Negotiated Rate |
$15,986.77 |
| Max. Negotiated Rate |
$21,422.27 |
| Rate for Payer: EPIC Health Plan Medicare |
$15,986.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15,986.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,384.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21,422.27
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC
|
Facility
|
IP
|
$16,216.75
|
|
|
Service Code
|
MSDRG 842
|
| Min. Negotiated Rate |
$12,102.05 |
| Max. Negotiated Rate |
$16,216.75 |
| Rate for Payer: EPIC Health Plan Medicare |
$12,102.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12,102.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,917.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16,216.75
|
|
