|
LEUCOVORIN CALCIUM 10 MG TABLET [4395]
|
Facility
IP
|
$7.48
|
|
|
Service Code
|
NDC 0054-4497-05
|
| 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
|
$7.48
|
|
|
Service Code
|
NDC 0054-4497-05
|
| 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
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
|
$6.65
|
|
|
Service Code
|
NDC 69315-185-24
|
| 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
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]
|
Facility
IP
|
$48.00
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
ERX15426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Adventist Health Commercial |
$5.53
|
| Rate for Payer: Adventist Health Commercial |
$5.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.98
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.50
|
| Rate for Payer: Heritage Provider Network Senior |
$32.50
|
| Rate for Payer: Heritage Provider Network Senior |
$19.50
|
| Rate for Payer: Heritage Provider Network Senior |
$18.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$20.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.04
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]
|
Facility
OP
|
$27.67
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
ERX15426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.01 |
| Max. Negotiated Rate |
$42.94 |
| Rate for Payer: Adventist Health Commercial |
$5.53
|
| Rate for Payer: Adventist Health Commercial |
$5.76
|
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.97
|
| 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 |
$32.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$23.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$24.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$36.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.60
|
| 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: 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 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: Blue Shield of California EPN |
$8.56
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: Dignity Health Senior |
$24.48
|
| Rate for Payer: Dignity Health Senior |
$40.80
|
| Rate for Payer: Dignity Health Senior |
$23.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.22
|
| Rate for Payer: Heritage Provider Network Senior |
$22.22
|
| Rate for Payer: Heritage Provider Network Senior |
$12.81
|
| Rate for Payer: Heritage Provider Network Senior |
$13.33
|
| Rate for Payer: IEHP Medi-Cal |
$13.93
|
| Rate for Payer: IEHP Medi-Cal |
$13.93
|
| Rate for Payer: IEHP Medi-Cal |
$13.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.20
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$20.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.52
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$24.48
|
| Rate for Payer: Vantage Medical Group Senior |
$23.52
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]
|
Facility
IP
|
$21.12
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$15.84 |
| Rate for Payer: Adventist Health Commercial |
$4.22
|
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Adventist Health Commercial |
$4.55
|
| Rate for Payer: Adventist Health Commercial |
$6.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$57.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.51
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$56.87
|
| Rate for Payer: Heritage Provider Network Senior |
$14.30
|
| Rate for Payer: Heritage Provider Network Senior |
$15.39
|
| Rate for Payer: Heritage Provider Network Senior |
$21.12
|
| Rate for Payer: Heritage Provider Network Senior |
$56.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$17.06
|
| Rate for Payer: Multiplan Commercial |
$23.40
|
| Rate for Payer: Multiplan Commercial |
$15.84
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.06
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]
|
Facility
OP
|
$22.74
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.12 |
| Max. Negotiated Rate |
$42.94 |
| Rate for Payer: Adventist Health Commercial |
$4.55
|
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Adventist Health Commercial |
$6.24
|
| Rate for Payer: Adventist Health Commercial |
$4.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.97
|
| 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 |
$57.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$46.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$63.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.40
|
| 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: 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 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: Blue Shield of California EPN |
$8.56
|
| Rate for Payer: Blue Shield of California EPN |
$8.56
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.40
|
| Rate for Payer: Dignity Health Senior |
$71.40
|
| Rate for Payer: Dignity Health Senior |
$17.95
|
| Rate for Payer: Dignity Health Senior |
$19.33
|
| Rate for Payer: Dignity Health Senior |
$26.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.89
|
| Rate for Payer: Heritage Provider Network Senior |
$10.53
|
| Rate for Payer: Heritage Provider Network Senior |
$38.89
|
| Rate for Payer: Heritage Provider Network Senior |
$14.45
|
| Rate for Payer: Heritage Provider Network Senior |
$9.78
|
| Rate for Payer: IEHP Medi-Cal |
$13.93
|
| Rate for Payer: IEHP Medi-Cal |
$13.93
|
| Rate for Payer: IEHP Medi-Cal |
$13.93
|
| Rate for Payer: IEHP Medi-Cal |
$13.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$40.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$17.06
|
| Rate for Payer: Multiplan Commercial |
$15.84
|
| Rate for Payer: Multiplan Commercial |
$23.40
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.52
|
| Rate for Payer: Vantage Medical Group Senior |
$19.33
|
| Rate for Payer: Vantage Medical Group Senior |
$17.95
|
| Rate for Payer: Vantage Medical Group Senior |
$26.52
|
| Rate for Payer: Vantage Medical Group Senior |
$71.40
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]
|
Facility
OP
|
$103.43
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
ERX23617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$87.92 |
| Rate for Payer: Adventist Health Commercial |
$20.69
|
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| 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 |
$82.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$71.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$87.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$56.89
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$90.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$77.57
|
| 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 |
$54.00
|
| Rate for Payer: Cash Price |
$46.54
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$46.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$47.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$87.92
|
| Rate for Payer: Dignity Health Senior |
$102.00
|
| Rate for Payer: Dignity Health Senior |
$87.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.56
|
| Rate for Payer: Heritage Provider Network Senior |
$47.89
|
| Rate for Payer: Heritage Provider Network Senior |
$55.56
|
| Rate for Payer: IEHP Medi-Cal |
$13.93
|
| Rate for Payer: IEHP Medi-Cal |
$13.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$49.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$57.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.86
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$77.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$87.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.00
|
| Rate for Payer: Vantage Medical Group Senior |
$87.92
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]
|
Facility
IP
|
$120.00
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
ERX23617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.72 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Adventist Health Commercial |
$20.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$71.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.44
|
| Rate for Payer: Cash Price |
$46.54
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$47.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$70.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.24
|
| Rate for Payer: Heritage Provider Network Senior |
$70.02
|
| Rate for Payer: Heritage Provider Network Senior |
$81.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: Multiplan Commercial |
$77.57
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.09
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
IP
|
$12.00
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Adventist Health Commercial |
$1.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.24
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.12
|
| Rate for Payer: Heritage Provider Network Senior |
$4.29
|
| Rate for Payer: Heritage Provider Network Senior |
$8.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$4.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.01
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
OP
|
$6.34
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
1720078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$42.94 |
| Rate for Payer: Adventist Health Commercial |
$1.27
|
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| 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 |
$4.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.00
|
| 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 |
$2.85
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.39
|
| Rate for Payer: Dignity Health Senior |
$10.20
|
| Rate for Payer: Dignity Health Senior |
$5.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Senior |
$5.56
|
| Rate for Payer: Heritage Provider Network Senior |
$2.94
|
| Rate for Payer: IEHP Medi-Cal |
$13.93
|
| Rate for Payer: IEHP Medi-Cal |
$13.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$4.76
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.39
|
| Rate for Payer: Vantage Medical Group Senior |
$5.39
|
| Rate for Payer: Vantage Medical Group Senior |
$10.20
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
OP
|
$1.89
|
|
|
Service Code
|
NDC 0054-8496-19
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1.17
|
| Rate for Payer: Blue Shield of California EPN |
$1.11
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.61
|
| Rate for Payer: Dignity Health Senior |
$1.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.17
|
| Rate for Payer: Heritage Provider Network Senior |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.61
|
| Rate for Payer: Vantage Medical Group Senior |
$1.61
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
IP
|
$1.89
|
|
|
Service Code
|
NDC 0054-8496-19
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.30
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
IP
|
$1.34
|
|
|
Service Code
|
NDC 0054-4496-13
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.92
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
OP
|
$1.34
|
|
|
Service Code
|
NDC 0054-4496-13
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Senior |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
IP
|
$1.34
|
|
|
Service Code
|
NDC 69315-184-03
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.92
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
OP
|
$1.34
|
|
|
Service Code
|
NDC 69315-184-03
|
| Hospital Charge Code |
1711174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Senior |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]
|
Facility
IP
|
$5,881.22
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
ERX21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,064.50 |
| Max. Negotiated Rate |
$4,410.92 |
| Rate for Payer: Adventist Health Commercial |
$1,176.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,040.40
|
| Rate for Payer: Cash Price |
$2,646.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,705.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,175.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,981.59
|
| Rate for Payer: Heritage Provider Network Senior |
$3,981.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,064.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,470.30
|
| Rate for Payer: Multiplan Commercial |
$4,410.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,144.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,964.92
|
|
|
LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]
|
Facility
OP
|
$5,881.22
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
ERX21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$960.05 |
| Max. Negotiated Rate |
$4,410.92 |
| Rate for Payer: Adventist Health Commercial |
$1,176.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,843.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,040.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,955.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,721.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,721.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$960.05
|
| Rate for Payer: Blue Shield of California Commercial |
$1,586.98
|
| Rate for Payer: Blue Shield of California EPN |
$1,586.98
|
| Rate for Payer: Cash Price |
$2,646.55
|
| Rate for Payer: Cash Price |
$2,646.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,705.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,346.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,721.06
|
| Rate for Payer: Dignity Health Senior |
$1,721.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,763.98
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,564.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,723.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2,723.00
|
| Rate for Payer: Humana Medicare |
$1,564.60
|
| Rate for Payer: IEHP Medi-Cal |
$2,447.73
|
| Rate for Payer: IEHP Medicare Advantage |
$1,564.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,972.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,064.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,846.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,470.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,971.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,971.40
|
| Rate for Payer: Multiplan Commercial |
$4,410.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,721.06
|
| Rate for Payer: TriValley Medical Group Senior |
$1,564.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,144.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,964.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,346.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,721.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1,564.60
|
|
|
LEUPROLIDE 11.25 MG INTRAMUSCULAR KIT [10390]
|
Facility
IP
|
$4,281.55
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
1722009
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$774.96 |
| Max. Negotiated Rate |
$3,211.16 |
| Rate for Payer: Adventist Health Commercial |
$856.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,941.42
|
| Rate for Payer: Cash Price |
$1,926.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,969.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,312.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,898.61
|
| Rate for Payer: Heritage Provider Network Senior |
$2,898.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$774.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,070.39
|
| Rate for Payer: Multiplan Commercial |
$3,211.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,561.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,430.47
|
|
|
LEUPROLIDE 11.25 MG INTRAMUSCULAR KIT [10390]
|
Facility
OP
|
$4,281.55
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
1722009
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$774.96 |
| Max. Negotiated Rate |
$3,843.64 |
| Rate for Payer: Adventist Health Commercial |
$856.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,843.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,941.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,955.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,721.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,721.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$960.05
|
| Rate for Payer: Blue Shield of California Commercial |
$1,586.98
|
| Rate for Payer: Blue Shield of California EPN |
$1,586.98
|
| Rate for Payer: Cash Price |
$1,926.70
|
| Rate for Payer: Cash Price |
$1,926.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,969.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,346.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,721.06
|
| Rate for Payer: Dignity Health Senior |
$1,721.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,740.19
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,564.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,982.36
|
| Rate for Payer: Heritage Provider Network Senior |
$1,982.36
|
| Rate for Payer: Humana Medicare |
$1,564.60
|
| Rate for Payer: IEHP Medi-Cal |
$2,447.73
|
| Rate for Payer: IEHP Medicare Advantage |
$1,564.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,972.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$774.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,846.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,070.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,971.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,971.40
|
| Rate for Payer: Multiplan Commercial |
$3,211.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,721.06
|
| Rate for Payer: TriValley Medical Group Senior |
$1,564.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,561.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,430.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,346.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,721.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1,564.60
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT [14135]
|
Facility
OP
|
$855.36
|
|
|
Service Code
|
CPT J9218
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.74 |
| Max. Negotiated Rate |
$641.52 |
| Rate for Payer: Adventist Health Commercial |
$171.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$27.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$587.63
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$184.09
|
| Rate for Payer: Blue Shield of California Commercial |
$51.73
|
| Rate for Payer: Blue Shield of California EPN |
$51.73
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$393.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.12
|
| Rate for Payer: Dignity Health Senior |
$15.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$547.43
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$396.03
|
| Rate for Payer: Heritage Provider Network Senior |
$396.03
|
| Rate for Payer: Humana Medicare |
$13.74
|
| Rate for Payer: IEHP Medicare Advantage |
$13.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.32
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.12
|
| Rate for Payer: TriValley Medical Group Senior |
$13.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$311.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$285.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: Vantage Medical Group Senior |
$13.74
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT [14135]
|
Facility
IP
|
$855.36
|
|
|
Service Code
|
CPT J9218
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.82 |
| Max. Negotiated Rate |
$641.52 |
| Rate for Payer: Adventist Health Commercial |
$171.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$587.63
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$393.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$461.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$579.08
|
| Rate for Payer: Heritage Provider Network Senior |
$579.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.84
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$311.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$285.78
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT. [40814135]
|
Facility
IP
|
$855.36
|
|
|
Service Code
|
CPT J9218
|
| Hospital Charge Code |
1756590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.82 |
| Max. Negotiated Rate |
$641.52 |
| Rate for Payer: Adventist Health Commercial |
$171.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$587.63
|
| Rate for Payer: Cash Price |
$384.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$393.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$461.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$579.08
|
| Rate for Payer: Heritage Provider Network Senior |
$579.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.84
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$311.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$285.78
|
|
