|
DAROLUTAMIDE 300 MG TABLET [225419]
|
Facility
IP
|
$128.66
|
|
|
Service Code
|
NDC 50419-395-01
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.29 |
| Max. Negotiated Rate |
$96.50 |
| Rate for Payer: Adventist Health Commercial |
$25.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$88.39
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$87.10
|
| Rate for Payer: Heritage Provider Network Senior |
$87.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.16
|
| Rate for Payer: Multiplan Commercial |
$96.50
|
|
|
DARUNAVIR 600 MG TABLET [92851]
|
Facility
OP
|
$41.91
|
|
|
Service Code
|
NDC 59676-562-01
|
| Hospital Charge Code |
1712433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.59 |
| Max. Negotiated Rate |
$35.62 |
| Rate for Payer: Adventist Health Commercial |
$8.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$35.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$31.43
|
| Rate for Payer: Blue Shield of California Commercial |
$26.03
|
| Rate for Payer: Blue Shield of California EPN |
$24.60
|
| Rate for Payer: Cash Price |
$18.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.62
|
| Rate for Payer: Dignity Health Senior |
$35.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.94
|
| Rate for Payer: Heritage Provider Network Senior |
$25.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.48
|
| Rate for Payer: Multiplan Commercial |
$31.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.62
|
| Rate for Payer: Vantage Medical Group Senior |
$35.62
|
|
|
DARUNAVIR 600 MG TABLET [92851]
|
Facility
IP
|
$41.91
|
|
|
Service Code
|
NDC 59676-562-01
|
| Hospital Charge Code |
1712433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.59 |
| Max. Negotiated Rate |
$31.43 |
| Rate for Payer: Adventist Health Commercial |
$8.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.79
|
| Rate for Payer: Cash Price |
$18.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.37
|
| Rate for Payer: Heritage Provider Network Senior |
$28.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.48
|
| Rate for Payer: Multiplan Commercial |
$31.43
|
|
|
DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET [208697]
|
Facility
OP
|
$95.80
|
|
|
Service Code
|
NDC 59676-575-30
|
| Hospital Charge Code |
ERX208697
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.34 |
| Max. Negotiated Rate |
$81.43 |
| Rate for Payer: Adventist Health Commercial |
$19.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$51.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$81.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$52.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$71.85
|
| Rate for Payer: Blue Shield of California Commercial |
$59.49
|
| Rate for Payer: Blue Shield of California EPN |
$56.23
|
| Rate for Payer: Cash Price |
$43.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$62.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.43
|
| Rate for Payer: Dignity Health Senior |
$81.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.30
|
| Rate for Payer: Heritage Provider Network Senior |
$59.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$46.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.95
|
| Rate for Payer: Multiplan Commercial |
$71.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.43
|
| Rate for Payer: Vantage Medical Group Senior |
$81.43
|
|
|
DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET [208697]
|
Facility
IP
|
$95.80
|
|
|
Service Code
|
NDC 59676-575-30
|
| Hospital Charge Code |
ERX208697
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.34 |
| Max. Negotiated Rate |
$71.85 |
| Rate for Payer: Adventist Health Commercial |
$19.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.81
|
| Rate for Payer: Cash Price |
$43.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.86
|
| Rate for Payer: Heritage Provider Network Senior |
$64.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.95
|
| Rate for Payer: Multiplan Commercial |
$71.85
|
|
|
DARUNAVIR 800 MG TABLET [199468]
|
Facility
IP
|
$83.81
|
|
|
Service Code
|
NDC 59676-566-30
|
| Hospital Charge Code |
1712557
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.17 |
| Max. Negotiated Rate |
$62.86 |
| Rate for Payer: Adventist Health Commercial |
$16.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$57.58
|
| Rate for Payer: Cash Price |
$37.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$56.74
|
| Rate for Payer: Heritage Provider Network Senior |
$56.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.95
|
| Rate for Payer: Multiplan Commercial |
$62.86
|
|
|
DARUNAVIR 800 MG TABLET [199468]
|
Facility
OP
|
$83.81
|
|
|
Service Code
|
NDC 59676-566-30
|
| Hospital Charge Code |
1712557
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.17 |
| Max. Negotiated Rate |
$71.24 |
| Rate for Payer: Adventist Health Commercial |
$16.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$44.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$57.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$71.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$46.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$62.86
|
| Rate for Payer: Blue Shield of California Commercial |
$52.05
|
| Rate for Payer: Blue Shield of California EPN |
$49.20
|
| Rate for Payer: Cash Price |
$37.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.24
|
| Rate for Payer: Dignity Health Senior |
$71.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.88
|
| Rate for Payer: Heritage Provider Network Senior |
$51.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$40.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.95
|
| Rate for Payer: Multiplan Commercial |
$62.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.24
|
| Rate for Payer: Vantage Medical Group Senior |
$71.24
|
|
|
DARUNAVIR 800 MG TABLET [199468]
|
Facility
IP
|
$72.41
|
|
|
Service Code
|
NDC 68180-346-06
|
| Hospital Charge Code |
1712557
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.11 |
| Max. Negotiated Rate |
$54.31 |
| Rate for Payer: Adventist Health Commercial |
$14.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.75
|
| Rate for Payer: Cash Price |
$32.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$49.02
|
| Rate for Payer: Heritage Provider Network Senior |
$49.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.10
|
| Rate for Payer: Multiplan Commercial |
$54.31
|
|
|
DARUNAVIR 800 MG TABLET [199468]
|
Facility
OP
|
$72.41
|
|
|
Service Code
|
NDC 68180-346-06
|
| Hospital Charge Code |
1712557
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.11 |
| Max. Negotiated Rate |
$61.55 |
| Rate for Payer: Adventist Health Commercial |
$14.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$61.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$39.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$54.31
|
| Rate for Payer: Blue Shield of California Commercial |
$44.97
|
| Rate for Payer: Blue Shield of California EPN |
$42.50
|
| Rate for Payer: Cash Price |
$32.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$47.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.55
|
| Rate for Payer: Dignity Health Senior |
$61.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.82
|
| Rate for Payer: Heritage Provider Network Senior |
$44.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$34.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.10
|
| Rate for Payer: Multiplan Commercial |
$54.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.55
|
| Rate for Payer: Vantage Medical Group Senior |
$61.55
|
|
|
DASATINIB 100 MG TABLET [92897]
|
Facility
IP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0852-22
|
| Hospital Charge Code |
1712498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$124.63 |
| Max. Negotiated Rate |
$516.40 |
| Rate for Payer: Adventist Health Commercial |
$137.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$473.03
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$371.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$466.14
|
| Rate for Payer: Heritage Provider Network Senior |
$466.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$124.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.14
|
| Rate for Payer: Multiplan Commercial |
$516.40
|
|
|
DASATINIB 100 MG TABLET [92897]
|
Facility
OP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0852-22
|
| Hospital Charge Code |
1712498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$124.63 |
| Max. Negotiated Rate |
$585.26 |
| Rate for Payer: Adventist Health Commercial |
$137.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$368.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$473.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$585.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$378.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$516.40
|
| Rate for Payer: Blue Shield of California Commercial |
$427.58
|
| Rate for Payer: Blue Shield of California EPN |
$404.17
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$447.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$585.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$585.26
|
| Rate for Payer: Dignity Health Senior |
$585.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$440.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$426.21
|
| Rate for Payer: Heritage Provider Network Senior |
$426.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$331.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$124.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.14
|
| Rate for Payer: Multiplan Commercial |
$516.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$585.26
|
| Rate for Payer: Vantage Medical Group Senior |
$585.26
|
|
|
DASATINIB 140 MG TABLET [108422]
|
Facility
OP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0857-22
|
| Hospital Charge Code |
1712499
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$124.63 |
| Max. Negotiated Rate |
$585.26 |
| Rate for Payer: Adventist Health Commercial |
$137.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$368.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$473.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$585.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$378.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$516.40
|
| Rate for Payer: Blue Shield of California Commercial |
$427.58
|
| Rate for Payer: Blue Shield of California EPN |
$404.17
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$447.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$585.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$585.26
|
| Rate for Payer: Dignity Health Senior |
$585.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$440.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$426.21
|
| Rate for Payer: Heritage Provider Network Senior |
$426.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$331.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$124.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.14
|
| Rate for Payer: Multiplan Commercial |
$516.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$585.26
|
| Rate for Payer: Vantage Medical Group Senior |
$585.26
|
|
|
DASATINIB 140 MG TABLET [108422]
|
Facility
IP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0857-22
|
| Hospital Charge Code |
1712499
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$124.63 |
| Max. Negotiated Rate |
$516.40 |
| Rate for Payer: Adventist Health Commercial |
$137.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$473.03
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$371.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$466.14
|
| Rate for Payer: Heritage Provider Network Senior |
$466.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$124.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.14
|
| Rate for Payer: Multiplan Commercial |
$516.40
|
|
|
DASATINIB 20 MG TABLET [76717]
|
Facility
IP
|
$191.01
|
|
|
Service Code
|
NDC 0003-0527-11
|
| Hospital Charge Code |
1711976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$34.57 |
| Max. Negotiated Rate |
$143.26 |
| Rate for Payer: Adventist Health Commercial |
$38.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$131.22
|
| Rate for Payer: Cash Price |
$85.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$103.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$129.31
|
| Rate for Payer: Heritage Provider Network Senior |
$129.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.75
|
| Rate for Payer: Multiplan Commercial |
$143.26
|
|
|
DASATINIB 20 MG TABLET [76717]
|
Facility
OP
|
$191.01
|
|
|
Service Code
|
NDC 0003-0527-11
|
| Hospital Charge Code |
1711976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$34.57 |
| Max. Negotiated Rate |
$162.36 |
| Rate for Payer: Adventist Health Commercial |
$38.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$102.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$131.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$162.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$105.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$143.26
|
| Rate for Payer: Blue Shield of California Commercial |
$118.62
|
| Rate for Payer: Blue Shield of California EPN |
$112.12
|
| Rate for Payer: Cash Price |
$85.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$124.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$162.36
|
| Rate for Payer: Dignity Health Senior |
$162.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$122.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$118.24
|
| Rate for Payer: Heritage Provider Network Senior |
$118.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$92.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.75
|
| Rate for Payer: Multiplan Commercial |
$143.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$162.36
|
| Rate for Payer: Vantage Medical Group Senior |
$162.36
|
|
|
DASATINIB 70 MG TABLET [76719]
|
Facility
OP
|
$382.03
|
|
|
Service Code
|
NDC 0003-0524-11
|
| Hospital Charge Code |
1711974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$69.15 |
| Max. Negotiated Rate |
$324.73 |
| Rate for Payer: Adventist Health Commercial |
$76.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$204.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$262.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$324.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$210.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$286.52
|
| Rate for Payer: Blue Shield of California Commercial |
$237.24
|
| Rate for Payer: Blue Shield of California EPN |
$224.25
|
| Rate for Payer: Cash Price |
$171.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$248.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$324.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$324.73
|
| Rate for Payer: Dignity Health Senior |
$324.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$244.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$236.48
|
| Rate for Payer: Heritage Provider Network Senior |
$236.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$184.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.51
|
| Rate for Payer: Multiplan Commercial |
$286.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$324.73
|
| Rate for Payer: Vantage Medical Group Senior |
$324.73
|
|
|
DASATINIB 70 MG TABLET [76719]
|
Facility
IP
|
$382.03
|
|
|
Service Code
|
NDC 0003-0524-11
|
| Hospital Charge Code |
1711974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$69.15 |
| Max. Negotiated Rate |
$286.52 |
| Rate for Payer: Adventist Health Commercial |
$76.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$262.45
|
| Rate for Payer: Cash Price |
$171.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$206.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$258.63
|
| Rate for Payer: Heritage Provider Network Senior |
$258.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.51
|
| Rate for Payer: Multiplan Commercial |
$286.52
|
|
|
DASATINIB 80 MG TABLET [108421]
|
Facility
OP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0855-22
|
| Hospital Charge Code |
1712500
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$124.63 |
| Max. Negotiated Rate |
$585.26 |
| Rate for Payer: Adventist Health Commercial |
$137.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$368.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$473.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$585.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$378.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$516.40
|
| Rate for Payer: Blue Shield of California Commercial |
$427.58
|
| Rate for Payer: Blue Shield of California EPN |
$404.17
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$447.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$585.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$585.26
|
| Rate for Payer: Dignity Health Senior |
$585.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$440.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$426.21
|
| Rate for Payer: Heritage Provider Network Senior |
$426.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$331.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$124.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.14
|
| Rate for Payer: Multiplan Commercial |
$516.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$585.26
|
| Rate for Payer: Vantage Medical Group Senior |
$585.26
|
|
|
DASATINIB 80 MG TABLET [108421]
|
Facility
IP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0855-22
|
| Hospital Charge Code |
1712500
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$124.63 |
| Max. Negotiated Rate |
$516.40 |
| Rate for Payer: Adventist Health Commercial |
$137.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$473.03
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$371.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$466.14
|
| Rate for Payer: Heritage Provider Network Senior |
$466.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$124.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.14
|
| Rate for Payer: Multiplan Commercial |
$516.40
|
|
|
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION [219514]
|
Facility
OP
|
$11,772.00
|
|
|
Service Code
|
CPT J9153
|
| Hospital Charge Code |
ERX219514
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$214.43 |
| Max. Negotiated Rate |
$8,829.00 |
| Rate for Payer: Adventist Health Commercial |
$2,354.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$456.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,087.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$289.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$254.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$254.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$387.71
|
| Rate for Payer: Blue Shield of California Commercial |
$214.43
|
| Rate for Payer: Blue Shield of California EPN |
$214.43
|
| Rate for Payer: Cash Price |
$5,297.40
|
| Rate for Payer: Cash Price |
$5,297.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,415.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$347.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$254.94
|
| Rate for Payer: Dignity Health Senior |
$254.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,534.08
|
| Rate for Payer: EPIC Health Plan Medicare |
$231.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,450.44
|
| Rate for Payer: Heritage Provider Network Senior |
$5,450.44
|
| Rate for Payer: Humana Medicare |
$231.76
|
| Rate for Payer: IEHP Medi-Cal |
$368.50
|
| Rate for Payer: IEHP Medicare Advantage |
$231.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$440.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,130.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$273.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,943.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$292.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$292.02
|
| Rate for Payer: Multiplan Commercial |
$8,829.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$254.94
|
| Rate for Payer: TriValley Medical Group Senior |
$231.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,292.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,933.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$347.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$254.94
|
| Rate for Payer: Vantage Medical Group Senior |
$231.76
|
|
|
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION [219514]
|
Facility
IP
|
$11,772.00
|
|
|
Service Code
|
CPT J9153
|
| Hospital Charge Code |
ERX219514
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,130.73 |
| Max. Negotiated Rate |
$8,829.00 |
| Rate for Payer: Adventist Health Commercial |
$2,354.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,087.36
|
| Rate for Payer: Cash Price |
$5,297.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,415.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,356.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,969.64
|
| Rate for Payer: Heritage Provider Network Senior |
$7,969.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,130.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,943.00
|
| Rate for Payer: Multiplan Commercial |
$8,829.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,292.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,933.03
|
|
|
DAUNORUBICIN 5 MG/ML INTRAVENOUS SOLUTION [22661]
|
Facility
OP
|
$39.34
|
|
|
Service Code
|
CPT J9150
|
| Hospital Charge Code |
1755125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.12 |
| Max. Negotiated Rate |
$166.77 |
| Rate for Payer: Adventist Health Commercial |
$7.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$70.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$44.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$39.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$39.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$166.77
|
| Rate for Payer: Blue Shield of California Commercial |
$68.41
|
| Rate for Payer: Blue Shield of California EPN |
$68.41
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$53.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.24
|
| Rate for Payer: Dignity Health Senior |
$39.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.18
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.21
|
| Rate for Payer: Heritage Provider Network Senior |
$18.21
|
| Rate for Payer: Humana Medicare |
$35.67
|
| Rate for Payer: IEHP Medi-Cal |
$62.60
|
| Rate for Payer: IEHP Medicare Advantage |
$35.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$67.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$42.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$44.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$44.95
|
| Rate for Payer: Multiplan Commercial |
$29.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$39.24
|
| Rate for Payer: TriValley Medical Group Senior |
$35.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$53.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.24
|
| Rate for Payer: Vantage Medical Group Senior |
$35.67
|
|
|
DAUNORUBICIN 5 MG/ML INTRAVENOUS SOLUTION [22661]
|
Facility
IP
|
$39.34
|
|
|
Service Code
|
CPT J9150
|
| Hospital Charge Code |
1755125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.12 |
| Max. Negotiated Rate |
$29.50 |
| Rate for Payer: Adventist Health Commercial |
$7.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.03
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.63
|
| Rate for Payer: Heritage Provider Network Senior |
$26.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.84
|
| Rate for Payer: Multiplan Commercial |
$29.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.14
|
|
|
Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 11047
|
| Min. Negotiated Rate |
$84.80 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$84.80
|
|
|
Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 11044
|
| Min. Negotiated Rate |
$315.95 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,025.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,228.26
|
| Rate for Payer: Dignity Health Senior |
$2,025.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,025.69
|
| Rate for Payer: Humana Medicare |
$2,025.69
|
| Rate for Payer: IEHP Medi-Cal |
$315.95
|
| Rate for Payer: IEHP Medicare Advantage |
$2,025.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,848.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,390.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,552.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,552.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,228.26
|
| Rate for Payer: TriValley Medical Group Senior |
$2,025.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.69
|
|
