|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 6846271408
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.83
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Senior |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
NDC 4257139212
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$1.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.88
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 3172259912
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.32
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
NDC 4257139212
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.16
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
|
|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 3172259912
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.20
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.52
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
RUFINAMIDE 40 MG/ML ORAL SUSPENSION [108804]
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
NDC 6285658446
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Adventist Health Commercial |
$0.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$2.80
|
| Rate for Payer: Blue Shield of California EPN |
$2.24
|
| Rate for Payer: Cash Price |
$2.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$3.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.84
|
| Rate for Payer: TriValley Medical Group Senior |
$1.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.90
|
| Rate for Payer: Vantage Medical Group Senior |
$3.90
|
|
|
RUFINAMIDE 40 MG/ML ORAL SUSPENSION [108804]
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
NDC 6285658446
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Adventist Health Commercial |
$0.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.96
|
| Rate for Payer: Cash Price |
$2.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.11
|
| Rate for Payer: Heritage Provider Network Senior |
$3.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$3.44
|
|
|
RUXOLITINIB 10 MG TABLET [153887]
|
Facility
|
IP
|
$363.80
|
|
|
Service Code
|
NDC 5088101060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$272.85 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$234.29
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$196.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$246.29
|
| Rate for Payer: Heritage Provider Network Senior |
$246.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$65.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.95
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
|
|
RUXOLITINIB 10 MG TABLET [153887]
|
Facility
|
OP
|
$363.80
|
|
|
Service Code
|
NDC 5088101060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$309.23 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$224.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$200.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$272.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$181.97
|
| Rate for Payer: Blue Shield of California Commercial |
$221.92
|
| Rate for Payer: Blue Shield of California EPN |
$177.53
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$236.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$309.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$309.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$309.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$232.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$225.19
|
| Rate for Payer: Heritage Provider Network Senior |
$225.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$173.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$65.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$254.66
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$145.52
|
| Rate for Payer: TriValley Medical Group Senior |
$145.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$181.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$181.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$309.23
|
| Rate for Payer: Vantage Medical Group Senior |
$309.23
|
|
|
RUXOLITINIB 15 MG TABLET [153888]
|
Facility
|
IP
|
$363.80
|
|
|
Service Code
|
NDC 5088101560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$272.85 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$234.29
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$196.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$246.29
|
| Rate for Payer: Heritage Provider Network Senior |
$246.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$65.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.95
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
|
|
RUXOLITINIB 15 MG TABLET [153888]
|
Facility
|
OP
|
$363.80
|
|
|
Service Code
|
NDC 5088101560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$309.23 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$224.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$200.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$272.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$181.97
|
| Rate for Payer: Blue Shield of California Commercial |
$221.92
|
| Rate for Payer: Blue Shield of California EPN |
$177.53
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$236.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$309.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$309.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$309.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$232.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$225.19
|
| Rate for Payer: Heritage Provider Network Senior |
$225.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$173.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$65.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$254.66
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$145.52
|
| Rate for Payer: TriValley Medical Group Senior |
$145.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$181.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$181.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$309.23
|
| Rate for Payer: Vantage Medical Group Senior |
$309.23
|
|
|
RUXOLITINIB 20 MG TABLET [153889]
|
Facility
|
IP
|
$363.80
|
|
|
Service Code
|
NDC 5088102060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$272.85 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$234.29
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$196.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$246.29
|
| Rate for Payer: Heritage Provider Network Senior |
$246.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$65.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.95
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
|
|
RUXOLITINIB 20 MG TABLET [153889]
|
Facility
|
OP
|
$363.80
|
|
|
Service Code
|
NDC 5088102060
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$309.23 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$224.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$200.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$272.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$181.97
|
| Rate for Payer: Blue Shield of California Commercial |
$221.92
|
| Rate for Payer: Blue Shield of California EPN |
$177.53
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$236.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$309.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$309.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$309.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$232.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$225.19
|
| Rate for Payer: Heritage Provider Network Senior |
$225.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$173.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$65.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$254.66
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$145.52
|
| Rate for Payer: TriValley Medical Group Senior |
$145.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$181.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$181.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$309.23
|
| Rate for Payer: Vantage Medical Group Senior |
$309.23
|
|
|
RUXOLITINIB 25 MG TABLET [153890]
|
Facility
|
OP
|
$363.80
|
|
|
Service Code
|
NDC 5088102560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$309.23 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$224.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$200.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$272.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$181.97
|
| Rate for Payer: Blue Shield of California Commercial |
$221.92
|
| Rate for Payer: Blue Shield of California EPN |
$177.53
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$236.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$309.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$309.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$309.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$232.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$225.19
|
| Rate for Payer: Heritage Provider Network Senior |
$225.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$173.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$65.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$254.66
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$145.52
|
| Rate for Payer: TriValley Medical Group Senior |
$145.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$181.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$181.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$309.23
|
| Rate for Payer: Vantage Medical Group Senior |
$309.23
|
|
|
RUXOLITINIB 25 MG TABLET [153890]
|
Facility
|
IP
|
$363.80
|
|
|
Service Code
|
NDC 5088102560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$272.85 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$234.29
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$196.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$246.29
|
| Rate for Payer: Heritage Provider Network Senior |
$246.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$65.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.95
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
|
|
RUXOLITINIB 5 MG TABLET [153886]
|
Facility
|
IP
|
$363.80
|
|
|
Service Code
|
NDC 5088100560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$272.85 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$234.29
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$196.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$246.29
|
| Rate for Payer: Heritage Provider Network Senior |
$246.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$65.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.95
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
|
|
RUXOLITINIB 5 MG TABLET [153886]
|
Facility
|
OP
|
$363.80
|
|
|
Service Code
|
NDC 5088100560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$309.23 |
| Rate for Payer: Adventist Health Commercial |
$72.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$224.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$200.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$272.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$181.97
|
| Rate for Payer: Blue Shield of California Commercial |
$221.92
|
| Rate for Payer: Blue Shield of California EPN |
$177.53
|
| Rate for Payer: Cash Price |
$163.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$236.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$309.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$309.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$309.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$232.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$225.19
|
| Rate for Payer: Heritage Provider Network Senior |
$225.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$173.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$65.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$254.66
|
| Rate for Payer: Multiplan Commercial |
$272.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$145.52
|
| Rate for Payer: TriValley Medical Group Senior |
$145.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$181.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$181.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$309.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$309.23
|
| Rate for Payer: Vantage Medical Group Senior |
$309.23
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [227764]
|
Facility
|
IP
|
$3,137.72
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$567.93 |
| Max. Negotiated Rate |
$2,353.29 |
| Rate for Payer: Adventist Health Commercial |
$627.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,020.69
|
| Rate for Payer: Cash Price |
$1,411.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,443.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,694.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,452.76
|
| Rate for Payer: Heritage Provider Network Senior |
$1,452.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$567.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$784.43
|
| Rate for Payer: Multiplan Commercial |
$2,353.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,133.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,038.90
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [227764]
|
Facility
|
OP
|
$3,137.72
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.91 |
| Max. Negotiated Rate |
$2,353.29 |
| Rate for Payer: Adventist Health Commercial |
$627.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,939.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$56.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$67.72
|
| Rate for Payer: Blue Shield of California Commercial |
$34.91
|
| Rate for Payer: Blue Shield of California EPN |
$34.91
|
| Rate for Payer: Cash Price |
$1,411.97
|
| Rate for Payer: Cash Price |
$1,411.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,443.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$41.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$41.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,008.14
|
| Rate for Payer: EPIC Health Plan Medicare |
$37.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,452.76
|
| Rate for Payer: Heritage Provider Network Senior |
$1,452.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37.64
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,496.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$567.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$43.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$784.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50.44
|
| Rate for Payer: Multiplan Commercial |
$2,353.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,255.09
|
| Rate for Payer: TriValley Medical Group Senior |
$1,255.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,133.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,038.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$47.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$41.40
|
| Rate for Payer: Vantage Medical Group Senior |
$41.40
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
OP
|
$1.04
|
|
|
Service Code
|
NDC 3334257009
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Senior |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Vantage Medical Group Senior |
$0.88
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 6233255660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.06
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 6233255660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Senior |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Vantage Medical Group Senior |
$1.39
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
OP
|
$14.53
|
|
|
Service Code
|
NDC 0078065920
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Adventist Health Commercial |
$2.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.27
|
| Rate for Payer: Blue Shield of California Commercial |
$8.86
|
| Rate for Payer: Blue Shield of California EPN |
$7.09
|
| Rate for Payer: Cash Price |
$6.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.99
|
| Rate for Payer: Heritage Provider Network Senior |
$8.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.17
|
| Rate for Payer: Multiplan Commercial |
$10.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.81
|
| Rate for Payer: TriValley Medical Group Senior |
$5.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.35
|
| Rate for Payer: Vantage Medical Group Senior |
$12.35
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
IP
|
$14.53
|
|
|
Service Code
|
NDC 0078065920
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$10.90 |
| Rate for Payer: Adventist Health Commercial |
$2.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.36
|
| Rate for Payer: Cash Price |
$6.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.84
|
| Rate for Payer: Heritage Provider Network Senior |
$9.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.63
|
| Rate for Payer: Multiplan Commercial |
$10.90
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
IP
|
$1.04
|
|
|
Service Code
|
NDC 3334257009
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.67
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
|
