|
LURASIDONE 40 MG TABLET [107668]
|
Facility
IP
|
$2.13
|
|
|
Service Code
|
NDC 47335-684-83
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
IP
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-21
|
| Hospital Charge Code |
1712502
|
|
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 |
$3.52
|
| 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 Permanente of CA 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 60687-758-11
|
| Hospital Charge Code |
1712502
|
|
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 Gatekeeper |
$2.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.85
|
| Rate for Payer: Blue Shield of California Commercial |
$3.19
|
| Rate for Payer: Blue Shield of California EPN |
$3.01
|
| 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 Senior |
$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 Permanente of CA Commercial |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
| 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
|
$5.13
|
|
|
Service Code
|
NDC 60687-758-11
|
| Hospital Charge Code |
1712502
|
|
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 |
$3.52
|
| 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 Permanente of CA 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 60687-758-21
|
| Hospital Charge Code |
1712502
|
|
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 Gatekeeper |
$2.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.85
|
| Rate for Payer: Blue Shield of California Commercial |
$3.19
|
| Rate for Payer: Blue Shield of California EPN |
$3.01
|
| 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 Senior |
$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 Permanente of CA Commercial |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
| 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
|
$56.75
|
|
|
Service Code
|
NDC 63402-304-30
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.27 |
| Max. Negotiated Rate |
$42.56 |
| Rate for Payer: Adventist Health Commercial |
$11.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.99
|
| Rate for Payer: Cash Price |
$25.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.42
|
| Rate for Payer: Heritage Provider Network Senior |
$38.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.19
|
| Rate for Payer: Multiplan Commercial |
$42.56
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
OP
|
$56.75
|
|
|
Service Code
|
NDC 63402-304-30
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.27 |
| Max. Negotiated Rate |
$48.24 |
| Rate for Payer: Adventist Health Commercial |
$11.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$30.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$48.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$31.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$42.56
|
| Rate for Payer: Blue Shield of California Commercial |
$35.24
|
| Rate for Payer: Blue Shield of California EPN |
$33.31
|
| Rate for Payer: Cash Price |
$25.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.24
|
| Rate for Payer: Dignity Health Senior |
$48.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.13
|
| Rate for Payer: Heritage Provider Network Senior |
$35.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$27.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.19
|
| Rate for Payer: Multiplan Commercial |
$42.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.24
|
| Rate for Payer: Vantage Medical Group Senior |
$48.24
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
OP
|
$2.13
|
|
|
Service Code
|
NDC 47335-684-83
|
| Hospital Charge Code |
1712502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.81
|
| Rate for Payer: Dignity Health Senior |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Senior |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [228261]
|
Facility
IP
|
$9,396.00
|
|
|
Service Code
|
NDC 68727-712-01
|
| Hospital Charge Code |
ERX408205864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,700.68 |
| Max. Negotiated Rate |
$7,047.00 |
| Rate for Payer: Adventist Health Commercial |
$1,879.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,455.05
|
| Rate for Payer: Cash Price |
$4,228.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,322.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,073.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,361.09
|
| Rate for Payer: Heritage Provider Network Senior |
$6,361.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,700.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,349.00
|
| Rate for Payer: Multiplan Commercial |
$7,047.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,425.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,139.20
|
|
|
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [228261]
|
Facility
OP
|
$9,396.00
|
|
|
Service Code
|
NDC 68727-712-01
|
| Hospital Charge Code |
ERX408205864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,700.68 |
| Max. Negotiated Rate |
$7,986.60 |
| Rate for Payer: Adventist Health Commercial |
$1,879.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5,022.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,455.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,986.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5,167.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,047.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,834.92
|
| Rate for Payer: Blue Shield of California EPN |
$5,515.45
|
| Rate for Payer: Cash Price |
$4,228.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,322.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,986.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,986.60
|
| Rate for Payer: Dignity Health Senior |
$7,986.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,013.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,350.35
|
| Rate for Payer: Heritage Provider Network Senior |
$4,350.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,528.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,700.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,349.00
|
| Rate for Payer: Multiplan Commercial |
$7,047.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,425.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,139.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,986.60
|
| Rate for Payer: Vantage Medical Group Senior |
$7,986.60
|
|
|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [225877]
|
Facility
IP
|
$4,559.88
|
|
|
Service Code
|
CPT J0896
|
| Hospital Charge Code |
ERX225877
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$825.34 |
| Max. Negotiated Rate |
$3,419.91 |
| Rate for Payer: Adventist Health Commercial |
$911.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,132.64
|
| Rate for Payer: Cash Price |
$2,051.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,097.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,462.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,087.04
|
| Rate for Payer: Heritage Provider Network Senior |
$3,087.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$825.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,139.97
|
| Rate for Payer: Multiplan Commercial |
$3,419.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,662.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,523.46
|
|
|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [225877]
|
Facility
OP
|
$4,559.88
|
|
|
Service Code
|
CPT J0896
|
| Hospital Charge Code |
ERX225877
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.26 |
| Max. Negotiated Rate |
$3,419.91 |
| Rate for Payer: Adventist Health Commercial |
$911.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$98.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,132.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$49.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$43.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$43.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.64
|
| Rate for Payer: Blue Shield of California Commercial |
$37.26
|
| Rate for Payer: Blue Shield of California EPN |
$37.26
|
| Rate for Payer: Cash Price |
$2,051.95
|
| Rate for Payer: Cash Price |
$2,051.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,097.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.97
|
| Rate for Payer: Dignity Health Senior |
$43.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,918.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$39.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,111.22
|
| Rate for Payer: Heritage Provider Network Senior |
$2,111.22
|
| Rate for Payer: Humana Medicare |
$39.97
|
| Rate for Payer: IEHP Medi-Cal |
$69.31
|
| Rate for Payer: IEHP Medicare Advantage |
$39.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$75.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$825.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$47.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,139.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$50.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$50.36
|
| Rate for Payer: Multiplan Commercial |
$3,419.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.97
|
| Rate for Payer: TriValley Medical Group Senior |
$39.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,662.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,523.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$49.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.97
|
| Rate for Payer: Vantage Medical Group Senior |
$43.97
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [225879]
|
Facility
IP
|
$13,679.62
|
|
|
Service Code
|
CPT J0896
|
| Hospital Charge Code |
ERX225879
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,476.01 |
| Max. Negotiated Rate |
$10,259.72 |
| Rate for Payer: Adventist Health Commercial |
$2,735.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9,397.90
|
| Rate for Payer: Cash Price |
$6,155.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6,292.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,386.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$9,261.10
|
| Rate for Payer: Heritage Provider Network Senior |
$9,261.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,476.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,419.90
|
| Rate for Payer: Multiplan Commercial |
$10,259.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,987.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,570.36
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [225879]
|
Facility
OP
|
$13,679.62
|
|
|
Service Code
|
CPT J0896
|
| Hospital Charge Code |
ERX225879
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.26 |
| Max. Negotiated Rate |
$10,259.72 |
| Rate for Payer: Adventist Health Commercial |
$2,735.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$98.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9,397.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$49.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$43.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$43.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.64
|
| Rate for Payer: Blue Shield of California Commercial |
$37.26
|
| Rate for Payer: Blue Shield of California EPN |
$37.26
|
| Rate for Payer: Cash Price |
$6,155.83
|
| Rate for Payer: Cash Price |
$6,155.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6,292.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.97
|
| Rate for Payer: Dignity Health Senior |
$43.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,754.96
|
| Rate for Payer: EPIC Health Plan Medicare |
$39.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,333.66
|
| Rate for Payer: Heritage Provider Network Senior |
$6,333.66
|
| Rate for Payer: Humana Medicare |
$39.97
|
| Rate for Payer: IEHP Medi-Cal |
$69.31
|
| Rate for Payer: IEHP Medicare Advantage |
$39.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$75.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,476.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$47.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,419.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$50.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$50.36
|
| Rate for Payer: Multiplan Commercial |
$10,259.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.97
|
| Rate for Payer: TriValley Medical Group Senior |
$39.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,987.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,570.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$49.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.97
|
| Rate for Payer: Vantage Medical Group Senior |
$43.97
|
|
|
LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [220890]
|
Facility
IP
|
$58,680.00
|
|
|
Service Code
|
CPT A9513
|
| Hospital Charge Code |
ERX220890
|
|
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 |
$40,313.16
|
| 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 Permanente of CA 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 |
$21,394.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19,604.99
|
|
|
LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [220890]
|
Facility
OP
|
$58,680.00
|
|
|
Service Code
|
CPT A9513
|
| Hospital Charge Code |
ERX220890
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$380.87 |
| Max. Negotiated Rate |
$44,010.00 |
| Rate for Payer: Adventist Health Commercial |
$11,736.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$542.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40,313.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$571.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$418.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$380.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$507.56
|
| Rate for Payer: Blue Shield of California Commercial |
$36,440.28
|
| Rate for Payer: Blue Shield of California EPN |
$34,445.16
|
| 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 |
$571.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$418.96
|
| Rate for Payer: Dignity Health Senior |
$380.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$37,555.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$380.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$36,322.92
|
| Rate for Payer: Heritage Provider Network Senior |
$36,322.92
|
| Rate for Payer: Humana Medicare |
$380.87
|
| Rate for Payer: IEHP Medi-Cal |
$434.40
|
| Rate for Payer: IEHP Medicare Advantage |
$380.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$723.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,621.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$449.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14,670.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$479.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$479.90
|
| Rate for Payer: Multiplan Commercial |
$44,010.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$418.96
|
| Rate for Payer: TriValley Medical Group Senior |
$380.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21,394.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19,604.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$571.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$418.96
|
| Rate for Payer: Vantage Medical Group Senior |
$380.87
|
|
|
LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [233901]
|
Facility
IP
|
$52,020.00
|
|
|
Service Code
|
CPT A9607
|
| Hospital Charge Code |
NDG233901
|
|
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 |
$35,737.74
|
| 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 Permanente of CA 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 |
$18,966.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17,379.88
|
|
|
LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [233901]
|
Facility
OP
|
$52,020.00
|
|
|
Service Code
|
CPT A9607
|
| Hospital Charge Code |
NDG233901
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$229.76 |
| Max. Negotiated Rate |
$39,015.00 |
| Rate for Payer: Adventist Health Commercial |
$10,404.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$551.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35,737.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$344.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$252.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$229.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$454.13
|
| Rate for Payer: Blue Shield of California Commercial |
$32,304.42
|
| Rate for Payer: Blue Shield of California EPN |
$30,535.74
|
| 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 |
$287.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$252.73
|
| Rate for Payer: Dignity Health Senior |
$229.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$33,292.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$229.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$32,200.38
|
| Rate for Payer: Heritage Provider Network Senior |
$32,200.38
|
| Rate for Payer: Humana Medicare |
$229.76
|
| Rate for Payer: IEHP Medi-Cal |
$338.13
|
| Rate for Payer: IEHP Medicare Advantage |
$229.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$436.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,415.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$271.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13,005.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$289.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$289.49
|
| Rate for Payer: Multiplan Commercial |
$39,015.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$252.73
|
| Rate for Payer: TriValley Medical Group Senior |
$229.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18,966.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17,379.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$287.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$252.73
|
| Rate for Payer: Vantage Medical Group Senior |
$252.73
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
IP
|
$5,388.36
|
|
|
Service Code
|
APR-DRG 6941
|
| Min. Negotiated Rate |
$5,388.36 |
| Max. Negotiated Rate |
$5,388.36 |
| Rate for Payer: IEHP Medi-Cal |
$5,388.36
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
IP
|
$17,118.18
|
|
|
Service Code
|
APR-DRG 6944
|
| Min. Negotiated Rate |
$17,118.18 |
| Max. Negotiated Rate |
$17,118.18 |
| Rate for Payer: IEHP Medi-Cal |
$17,118.18
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
IP
|
$6,743.40
|
|
|
Service Code
|
APR-DRG 6942
|
| Min. Negotiated Rate |
$6,743.40 |
| Max. Negotiated Rate |
$6,743.40 |
| Rate for Payer: IEHP Medi-Cal |
$6,743.40
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
IP
|
$9,910.16
|
|
|
Service Code
|
APR-DRG 6943
|
| Min. Negotiated Rate |
$9,910.16 |
| Max. Negotiated Rate |
$9,910.16 |
| Rate for Payer: IEHP Medi-Cal |
$9,910.16
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
IP
|
$7,636.82
|
|
|
Service Code
|
APR-DRG 6911
|
| Min. Negotiated Rate |
$7,636.82 |
| Max. Negotiated Rate |
$7,636.82 |
| Rate for Payer: IEHP Medi-Cal |
$7,636.82
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
IP
|
$14,827.92
|
|
|
Service Code
|
APR-DRG 6913
|
| Min. Negotiated Rate |
$14,827.92 |
| Max. Negotiated Rate |
$14,827.92 |
| Rate for Payer: IEHP Medi-Cal |
$14,827.92
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
IP
|
$9,898.22
|
|
|
Service Code
|
APR-DRG 6912
|
| Min. Negotiated Rate |
$9,898.22 |
| Max. Negotiated Rate |
$9,898.22 |
| Rate for Payer: IEHP Medi-Cal |
$9,898.22
|
|
