|
RIZATRIPTAN 5 MG TABLET [23376]
|
Facility
IP
|
$1.44
|
|
|
Service Code
|
NDC 68462-465-40
|
| Hospital Charge Code |
1712622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.99
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
|
|
RIZATRIPTAN 5 MG TABLET [23376]
|
Facility
IP
|
$1.44
|
|
|
Service Code
|
NDC 68462-465-99
|
| Hospital Charge Code |
1712622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.99
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
|
|
ROCURONIUM 50 MG/5 ML VIAL- CODE [40895812]
|
Facility
IP
|
$1.16
|
|
|
Service Code
|
NDC 67457-228-05
|
| Hospital Charge Code |
1722005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
|
|
ROCURONIUM 50 MG/5 ML VIAL- CODE [40895812]
|
Facility
OP
|
$1.16
|
|
|
Service Code
|
NDC 67457-228-05
|
| Hospital Charge Code |
1722005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.72
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: Dignity Health Senior |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
ROFLUMILAST 500 MCG TABLET [109401]
|
Facility
OP
|
$0.72
|
|
|
Service Code
|
NDC 72205-200-30
|
| Hospital Charge Code |
ERX109401
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
ROFLUMILAST 500 MCG TABLET [109401]
|
Facility
IP
|
$0.72
|
|
|
Service Code
|
NDC 72205-200-30
|
| Hospital Charge Code |
ERX109401
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
ROFLUMILAST 500 MCG TABLET [109401]
|
Facility
OP
|
$17.24
|
|
|
Service Code
|
NDC 0310-0095-30
|
| Hospital Charge Code |
ERX109401
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$14.65 |
| Rate for Payer: Adventist Health Commercial |
$3.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.93
|
| Rate for Payer: Blue Shield of California Commercial |
$10.71
|
| Rate for Payer: Blue Shield of California EPN |
$10.12
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.65
|
| Rate for Payer: Dignity Health Senior |
$14.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.67
|
| Rate for Payer: Heritage Provider Network Senior |
$10.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.31
|
| Rate for Payer: Multiplan Commercial |
$12.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.65
|
| Rate for Payer: Vantage Medical Group Senior |
$14.65
|
|
|
ROFLUMILAST 500 MCG TABLET [109401]
|
Facility
IP
|
$17.24
|
|
|
Service Code
|
NDC 0310-0095-30
|
| Hospital Charge Code |
ERX109401
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$12.93 |
| Rate for Payer: Adventist Health Commercial |
$3.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.84
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.67
|
| Rate for Payer: Heritage Provider Network Senior |
$11.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.31
|
| Rate for Payer: Multiplan Commercial |
$12.93
|
|
|
ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION [100344]
|
Facility
IP
|
$3,838.38
|
|
|
Service Code
|
CPT J9319
|
| Hospital Charge Code |
ERX100344
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$694.75 |
| Max. Negotiated Rate |
$2,878.78 |
| Rate for Payer: Adventist Health Commercial |
$767.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,636.97
|
| Rate for Payer: Cash Price |
$1,727.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,765.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,072.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,598.58
|
| Rate for Payer: Heritage Provider Network Senior |
$2,598.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$694.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$959.60
|
| Rate for Payer: Multiplan Commercial |
$2,878.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,399.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,282.40
|
|
|
ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION [100344]
|
Facility
OP
|
$3,838.38
|
|
|
Service Code
|
CPT J9319
|
| Hospital Charge Code |
ERX100344
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.96 |
| Max. Negotiated Rate |
$2,878.78 |
| Rate for Payer: Adventist Health Commercial |
$767.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$78.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,636.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$39.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$35.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$35.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$68.29
|
| Rate for Payer: Blue Shield of California Commercial |
$32.32
|
| Rate for Payer: Blue Shield of California EPN |
$32.32
|
| Rate for Payer: Cash Price |
$1,727.27
|
| Rate for Payer: Cash Price |
$1,727.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,765.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.16
|
| Rate for Payer: Dignity Health Senior |
$35.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,456.56
|
| Rate for Payer: EPIC Health Plan Medicare |
$31.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,777.17
|
| Rate for Payer: Heritage Provider Network Senior |
$1,777.17
|
| Rate for Payer: Humana Medicare |
$31.96
|
| Rate for Payer: IEHP Medi-Cal |
$56.82
|
| Rate for Payer: IEHP Medicare Advantage |
$31.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$60.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$694.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$37.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$959.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$40.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$40.27
|
| Rate for Payer: Multiplan Commercial |
$2,878.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$35.16
|
| Rate for Payer: TriValley Medical Group Senior |
$31.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,399.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,282.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$47.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.16
|
| Rate for Payer: Vantage Medical Group Senior |
$31.96
|
|
|
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION [226462]
|
Facility
OP
|
$1,431.00
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
ERX226462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.89 |
| Max. Negotiated Rate |
$1,073.25 |
| Rate for Payer: Adventist Health Commercial |
$286.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$235.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$983.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$120.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$105.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$105.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$92.67
|
| Rate for Payer: Blue Shield of California Commercial |
$91.89
|
| Rate for Payer: Blue Shield of California EPN |
$91.89
|
| Rate for Payer: Cash Price |
$643.95
|
| Rate for Payer: Cash Price |
$643.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$658.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$144.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$105.63
|
| Rate for Payer: Dignity Health Senior |
$105.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$915.84
|
| Rate for Payer: EPIC Health Plan Medicare |
$96.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$662.55
|
| Rate for Payer: Heritage Provider Network Senior |
$662.55
|
| Rate for Payer: Humana Medicare |
$96.03
|
| Rate for Payer: IEHP Medi-Cal |
$156.76
|
| Rate for Payer: IEHP Medicare Advantage |
$96.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$182.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$259.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$113.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$357.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$120.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$120.99
|
| Rate for Payer: Multiplan Commercial |
$1,073.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$105.63
|
| Rate for Payer: TriValley Medical Group Senior |
$96.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$521.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$478.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$144.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$105.63
|
| Rate for Payer: Vantage Medical Group Senior |
$96.03
|
|
|
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION [226462]
|
Facility
IP
|
$1,431.00
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
ERX226462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$259.01 |
| Max. Negotiated Rate |
$1,073.25 |
| Rate for Payer: Adventist Health Commercial |
$286.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$983.10
|
| Rate for Payer: Cash Price |
$643.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$658.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$772.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$968.79
|
| Rate for Payer: Heritage Provider Network Senior |
$968.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$259.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$357.75
|
| Rate for Payer: Multiplan Commercial |
$1,073.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$521.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$478.10
|
|
|
ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION [93566]
|
Facility
IP
|
$2,861.96
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
1721175
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$518.01 |
| Max. Negotiated Rate |
$2,146.47 |
| Rate for Payer: Adventist Health Commercial |
$572.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,966.17
|
| Rate for Payer: Cash Price |
$1,287.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,316.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,545.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,937.55
|
| Rate for Payer: Heritage Provider Network Senior |
$1,937.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$518.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$715.49
|
| Rate for Payer: Multiplan Commercial |
$2,146.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,043.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$956.18
|
|
|
ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION [93566]
|
Facility
OP
|
$2,861.96
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
1721175
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.89 |
| Max. Negotiated Rate |
$2,146.47 |
| Rate for Payer: Adventist Health Commercial |
$572.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$235.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,966.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$120.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$105.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$105.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$92.67
|
| Rate for Payer: Blue Shield of California Commercial |
$91.89
|
| Rate for Payer: Blue Shield of California EPN |
$91.89
|
| Rate for Payer: Cash Price |
$1,287.88
|
| Rate for Payer: Cash Price |
$1,287.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,316.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$144.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$105.63
|
| Rate for Payer: Dignity Health Senior |
$105.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,831.65
|
| Rate for Payer: EPIC Health Plan Medicare |
$96.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,325.09
|
| Rate for Payer: Heritage Provider Network Senior |
$1,325.09
|
| Rate for Payer: Humana Medicare |
$96.03
|
| Rate for Payer: IEHP Medi-Cal |
$156.76
|
| Rate for Payer: IEHP Medicare Advantage |
$96.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$182.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$518.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$113.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$715.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$120.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$120.99
|
| Rate for Payer: Multiplan Commercial |
$2,146.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$105.63
|
| Rate for Payer: TriValley Medical Group Senior |
$96.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,043.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$956.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$144.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$105.63
|
| Rate for Payer: Vantage Medical Group Senior |
$96.03
|
|
|
ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION [93567]
|
Facility
OP
|
$5,723.92
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
1721176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.89 |
| Max. Negotiated Rate |
$4,292.94 |
| Rate for Payer: Adventist Health Commercial |
$1,144.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$235.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,932.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$120.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$105.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$105.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$92.67
|
| Rate for Payer: Blue Shield of California Commercial |
$91.89
|
| Rate for Payer: Blue Shield of California EPN |
$91.89
|
| Rate for Payer: Cash Price |
$2,575.76
|
| Rate for Payer: Cash Price |
$2,575.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,633.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$144.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$105.63
|
| Rate for Payer: Dignity Health Senior |
$105.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,663.31
|
| Rate for Payer: EPIC Health Plan Medicare |
$96.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,650.17
|
| Rate for Payer: Heritage Provider Network Senior |
$2,650.17
|
| Rate for Payer: Humana Medicare |
$96.03
|
| Rate for Payer: IEHP Medi-Cal |
$156.76
|
| Rate for Payer: IEHP Medicare Advantage |
$96.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$182.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,036.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$113.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,430.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$120.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$120.99
|
| Rate for Payer: Multiplan Commercial |
$4,292.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$105.63
|
| Rate for Payer: TriValley Medical Group Senior |
$96.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,086.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,912.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$144.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$105.63
|
| Rate for Payer: Vantage Medical Group Senior |
$96.03
|
|
|
ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION [93567]
|
Facility
IP
|
$5,723.92
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
1721176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,036.03 |
| Max. Negotiated Rate |
$4,292.94 |
| Rate for Payer: Adventist Health Commercial |
$1,144.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,932.33
|
| Rate for Payer: Cash Price |
$2,575.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,633.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,090.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,875.09
|
| Rate for Payer: Heritage Provider Network Senior |
$3,875.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,036.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,430.98
|
| Rate for Payer: Multiplan Commercial |
$4,292.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,086.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,912.36
|
|
|
ROPINIROLE 0.25 MG TABLET [21688]
|
Facility
OP
|
$0.59
|
|
|
Service Code
|
NDC 0904-6373-61
|
| Hospital Charge Code |
1711813
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.50
|
| Rate for Payer: Dignity Health Senior |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Vantage Medical Group Senior |
$0.50
|
|
|
ROPINIROLE 0.25 MG TABLET [21688]
|
Facility
IP
|
$0.66
|
|
|
Service Code
|
NDC 60687-577-01
|
| Hospital Charge Code |
1711813
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
ROPINIROLE 0.25 MG TABLET [21688]
|
Facility
IP
|
$0.59
|
|
|
Service Code
|
NDC 0904-6373-61
|
| Hospital Charge Code |
1711813
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
ROPINIROLE 0.25 MG TABLET [21688]
|
Facility
IP
|
$0.66
|
|
|
Service Code
|
NDC 60687-577-11
|
| Hospital Charge Code |
1711813
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
ROPINIROLE 0.25 MG TABLET [21688]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 62332-030-31
|
| Hospital Charge Code |
1711813
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
ROPINIROLE 0.25 MG TABLET [21688]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 62332-030-31
|
| Hospital Charge Code |
1711813
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
ROPINIROLE 0.25 MG TABLET [21688]
|
Facility
OP
|
$0.66
|
|
|
Service Code
|
NDC 60687-577-11
|
| Hospital Charge Code |
1711813
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.56
|
| Rate for Payer: Dignity Health Senior |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Vantage Medical Group Senior |
$0.56
|
|
|
ROPINIROLE 0.25 MG TABLET [21688]
|
Facility
OP
|
$0.66
|
|
|
Service Code
|
NDC 60687-577-01
|
| Hospital Charge Code |
1711813
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.56
|
| Rate for Payer: Dignity Health Senior |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Vantage Medical Group Senior |
$0.56
|
|
|
ROPINIROLE 0.5 MG TABLET [21800]
|
Facility
OP
|
$0.14
|
|
|
Service Code
|
NDC 68462-254-01
|
| Hospital Charge Code |
1711816
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
