|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
OP
|
$6.00
|
|
|
Service Code
|
NDC 62332-062-30
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Blue Shield of California Commercial |
$3.73
|
| Rate for Payer: Blue Shield of California EPN |
$3.52
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Senior |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.71
|
| Rate for Payer: Heritage Provider Network Senior |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
OP
|
$3.32
|
|
|
Service Code
|
NDC 60505-2503-1
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.49
|
| Rate for Payer: Blue Shield of California Commercial |
$2.06
|
| Rate for Payer: Blue Shield of California EPN |
$1.95
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.82
|
| Rate for Payer: Dignity Health Senior |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.06
|
| Rate for Payer: Heritage Provider Network Senior |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Vantage Medical Group Senior |
$2.82
|
|
|
LEFLUNOMIDE 20 MG TABLET [23873]
|
Facility
OP
|
$0.88
|
|
|
Service Code
|
NDC 23155-044-03
|
| Hospital Charge Code |
1710881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.75
|
| Rate for Payer: Dignity Health Senior |
$0.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.75
|
|
|
Lengthening of tendon, flexor, hand or finger, each tendon
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 26478
|
| Min. Negotiated Rate |
$105.13 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: Dignity Health Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,044.21
|
| Rate for Payer: Humana Medicare |
$4,044.21
|
| Rate for Payer: IEHP Medi-Cal |
$105.13
|
| Rate for Payer: IEHP Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,684.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,772.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,095.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,448.63
|
| Rate for Payer: TriValley Medical Group Senior |
$4,044.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendon
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 25280
|
| Min. Negotiated Rate |
$108.61 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: Dignity Health Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,044.21
|
| Rate for Payer: Humana Medicare |
$4,044.21
|
| Rate for Payer: IEHP Medi-Cal |
$108.61
|
| Rate for Payer: IEHP Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,684.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,772.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,095.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,448.63
|
| Rate for Payer: TriValley Medical Group Senior |
$4,044.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
OP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-02
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$14.64 |
| Rate for Payer: Adventist Health Commercial |
$3.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.92
|
| Rate for Payer: Blue Shield of California Commercial |
$10.69
|
| Rate for Payer: Blue Shield of California EPN |
$10.11
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.64
|
| Rate for Payer: Dignity Health Senior |
$14.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.66
|
| Rate for Payer: Heritage Provider Network Senior |
$10.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.30
|
| Rate for Payer: Multiplan Commercial |
$12.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.64
|
| Rate for Payer: Vantage Medical Group Senior |
$14.64
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
IP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-01
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$12.92 |
| Rate for Payer: Adventist Health Commercial |
$3.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.83
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.66
|
| Rate for Payer: Heritage Provider Network Senior |
$11.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.30
|
| Rate for Payer: Multiplan Commercial |
$12.92
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
OP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-01
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$14.64 |
| Rate for Payer: Adventist Health Commercial |
$3.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.92
|
| Rate for Payer: Blue Shield of California Commercial |
$10.69
|
| Rate for Payer: Blue Shield of California EPN |
$10.11
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.64
|
| Rate for Payer: Dignity Health Senior |
$14.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.66
|
| Rate for Payer: Heritage Provider Network Senior |
$10.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.30
|
| Rate for Payer: Multiplan Commercial |
$12.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.64
|
| Rate for Payer: Vantage Medical Group Senior |
$14.64
|
|
|
LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]
|
Facility
IP
|
$17.22
|
|
|
Service Code
|
NDC 0006-5004-02
|
| Hospital Charge Code |
NDG220341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$12.92 |
| Rate for Payer: Adventist Health Commercial |
$3.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.83
|
| Rate for Payer: Cash Price |
$7.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.66
|
| Rate for Payer: Heritage Provider Network Senior |
$11.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.30
|
| Rate for Payer: Multiplan Commercial |
$12.92
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
OP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-15
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Senior |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 16729-034-10
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 16729-034-10
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
IP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-15
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
IP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-11
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
LETROZOLE 2.5 MG TABLET [21509]
|
Facility
OP
|
$0.67
|
|
|
Service Code
|
NDC 50268-476-11
|
| Hospital Charge Code |
1710976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Senior |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
LEUCINE 0.1 GRAM-15 KCAL/4 GRAM ORAL POWDER PACKET [78240]
|
Facility
IP
|
$4.80
|
|
|
Service Code
|
NDC 5060054920
|
| Hospital Charge Code |
ERX78240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.30
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.25
|
| Rate for Payer: Heritage Provider Network Senior |
$3.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
|
|
LEUCINE 0.1 GRAM-15 KCAL/4 GRAM ORAL POWDER PACKET [78240]
|
Facility
OP
|
$4.80
|
|
|
Service Code
|
NDC 5060054920
|
| Hospital Charge Code |
ERX78240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Blue Shield of California Commercial |
$2.98
|
| Rate for Payer: Blue Shield of California EPN |
$2.82
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Senior |
$4.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.97
|
| Rate for Payer: Heritage Provider Network Senior |
$2.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]
|
Facility
IP
|
$24.00
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Adventist Health Commercial |
$3.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.49
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.25
|
| Rate for Payer: Heritage Provider Network Senior |
$13.00
|
| Rate for Payer: Heritage Provider Network Senior |
$16.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.41
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]
|
Facility
OP
|
$19.20
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$42.94 |
| Rate for Payer: Adventist Health Commercial |
$3.84
|
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.94
|
| Rate for Payer: Blue Shield of California Commercial |
$8.56
|
| Rate for Payer: Blue Shield of California Commercial |
$8.56
|
| Rate for Payer: Blue Shield of California EPN |
$8.56
|
| Rate for Payer: Blue Shield of California EPN |
$8.56
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.32
|
| Rate for Payer: Dignity Health Senior |
$20.40
|
| Rate for Payer: Dignity Health Senior |
$16.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.89
|
| Rate for Payer: Heritage Provider Network Senior |
$8.89
|
| Rate for Payer: Heritage Provider Network Senior |
$11.11
|
| Rate for Payer: IEHP Medi-Cal |
$13.93
|
| Rate for Payer: IEHP Medi-Cal |
$13.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$16.32
|
| Rate for Payer: Vantage Medical Group Senior |
$20.40
|
|
|
LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [15370]
|
Facility
IP
|
$2.84
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
NDG15370A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.95
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Senior |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.95
|
|
|
LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [15370]
|
Facility
OP
|
$2.84
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
NDG15370A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$42.94 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.94
|
| Rate for Payer: Blue Shield of California Commercial |
$8.56
|
| Rate for Payer: Blue Shield of California EPN |
$8.56
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.41
|
| Rate for Payer: Dignity Health Senior |
$2.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: IEHP Medi-Cal |
$13.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.41
|
| Rate for Payer: Vantage Medical Group Senior |
$2.41
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
OP
|
$7.48
|
|
|
Service Code
|
NDC 69315-185-12
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$6.36 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.61
|
| Rate for Payer: Blue Shield of California Commercial |
$4.65
|
| Rate for Payer: Blue Shield of California EPN |
$4.39
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.36
|
| Rate for Payer: Dignity Health Senior |
$6.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.63
|
| Rate for Payer: Heritage Provider Network Senior |
$4.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.87
|
| Rate for Payer: Multiplan Commercial |
$5.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: Vantage Medical Group Senior |
$6.36
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
IP
|
$7.48
|
|
|
Service Code
|
NDC 69315-185-12
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$5.61 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.14
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.06
|
| Rate for Payer: Heritage Provider Network Senior |
$5.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.87
|
| Rate for Payer: Multiplan Commercial |
$5.61
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
OP
|
$6.65
|
|
|
Service Code
|
NDC 0054-4497-10
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.65 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.99
|
| Rate for Payer: Blue Shield of California Commercial |
$4.13
|
| Rate for Payer: Blue Shield of California EPN |
$3.90
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.65
|
| Rate for Payer: Dignity Health Senior |
$5.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.12
|
| Rate for Payer: Heritage Provider Network Senior |
$4.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.66
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.65
|
| Rate for Payer: Vantage Medical Group Senior |
$5.65
|
|
|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
IP
|
$6.65
|
|
|
Service Code
|
NDC 0054-4497-10
|
| Hospital Charge Code |
1712574
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$4.99 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.57
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.50
|
| Rate for Payer: Heritage Provider Network Senior |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.66
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
|
