|
DD10BB1
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5513
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DD11B6Z
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5514
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DD11BB1
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5515
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DD12B6Z
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5516
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DD12BB1
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5517
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DD13B6Z
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5518
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DD13BB1
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5519
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DD14B6Z
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5520
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DD14BB1
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5521
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DD15B6Z
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5522
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DD15BB1
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5523
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DD17B6Z
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5524
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DD17BB1
|
Facility
|
IP
|
$8,769.00
|
|
| Hospital Charge Code |
5525
|
| Min. Negotiated Rate |
$8,769.00 |
| Max. Negotiated Rate |
$8,769.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,769.00
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
|
OP
|
$237.60
|
|
|
Service Code
|
HCPCS J0894
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$201.96 |
| Rate for Payer: Adventist Health Commercial |
$47.52
|
| Rate for Payer: Adventist Health Commercial |
$144.00
|
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$64.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$384.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$127.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$494.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$163.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$201.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$612.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$396.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$130.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$178.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$540.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$90.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.35
|
| Rate for Payer: Blue Shield of California Commercial |
$6.43
|
| Rate for Payer: Blue Shield of California Commercial |
$6.43
|
| Rate for Payer: Blue Shield of California Commercial |
$6.43
|
| Rate for Payer: Blue Shield of California EPN |
$6.43
|
| Rate for Payer: Blue Shield of California EPN |
$6.43
|
| Rate for Payer: Blue Shield of California EPN |
$6.43
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$130.68
|
| Rate for Payer: Cash Price |
$130.68
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$331.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$612.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$201.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$201.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$612.00
|
| Rate for Payer: Dignity Health Senior |
$612.00
|
| Rate for Payer: Dignity Health Senior |
$102.00
|
| Rate for Payer: Dignity Health Senior |
$201.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$460.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$333.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.01
|
| Rate for Payer: Heritage Provider Network Senior |
$333.36
|
| Rate for Payer: Heritage Provider Network Senior |
$55.56
|
| Rate for Payer: Heritage Provider Network Senior |
$110.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$343.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$57.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$113.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$180.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$166.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$504.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$84.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$504.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$166.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$84.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$178.20
|
| Rate for Payer: Multiplan Commercial |
$540.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$288.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$95.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$48.00
|
| Rate for Payer: TriValley Medical Group Senior |
$48.00
|
| Rate for Payer: TriValley Medical Group Senior |
$288.00
|
| Rate for Payer: TriValley Medical Group Senior |
$95.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$85.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$260.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$78.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$238.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$201.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$612.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$201.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$612.00
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
| Rate for Payer: Vantage Medical Group Senior |
$612.00
|
| Rate for Payer: Vantage Medical Group Senior |
$201.96
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
|
IP
|
$237.60
|
|
|
Service Code
|
HCPCS J0894
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.01 |
| Max. Negotiated Rate |
$178.20 |
| Rate for Payer: Adventist Health Commercial |
$47.52
|
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Adventist Health Commercial |
$144.00
|
| Rate for Payer: Cash Price |
$130.68
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$331.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$128.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$388.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$333.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.01
|
| Rate for Payer: Heritage Provider Network Senior |
$110.01
|
| Rate for Payer: Heritage Provider Network Senior |
$55.56
|
| Rate for Payer: Heritage Provider Network Senior |
$333.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$540.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$178.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$260.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$85.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$238.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$78.67
|
|
|
DEFERASIROX 180 MG TABLET [206427]
|
Facility
|
OP
|
$132.38
|
|
|
Service Code
|
NDC 0078-0655-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.96 |
| Max. Negotiated Rate |
$112.52 |
| Rate for Payer: Adventist Health Commercial |
$26.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$70.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$90.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$112.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$72.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$99.28
|
| Rate for Payer: Blue Shield of California Commercial |
$80.75
|
| Rate for Payer: Blue Shield of California EPN |
$64.60
|
| Rate for Payer: Cash Price |
$72.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$86.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$112.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$112.52
|
| Rate for Payer: Dignity Health Senior |
$112.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.94
|
| Rate for Payer: Heritage Provider Network Senior |
$81.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$63.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$92.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$92.67
|
| Rate for Payer: Multiplan Commercial |
$99.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$52.95
|
| Rate for Payer: TriValley Medical Group Senior |
$52.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$66.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$66.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$112.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$112.52
|
| Rate for Payer: Vantage Medical Group Senior |
$112.52
|
|
|
DEFERASIROX 180 MG TABLET [206427]
|
Facility
|
IP
|
$132.38
|
|
|
Service Code
|
NDC 0078-0655-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.96 |
| Max. Negotiated Rate |
$99.28 |
| Rate for Payer: Adventist Health Commercial |
$26.48
|
| Rate for Payer: Cash Price |
$72.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$89.62
|
| Rate for Payer: Heritage Provider Network Senior |
$89.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.09
|
| Rate for Payer: Multiplan Commercial |
$99.28
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
|
OP
|
$123.47
|
|
|
Service Code
|
NDC 0078-0469-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.35 |
| Max. Negotiated Rate |
$104.95 |
| Rate for Payer: Adventist Health Commercial |
$24.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$65.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$84.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$104.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$67.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$92.60
|
| Rate for Payer: Blue Shield of California Commercial |
$75.32
|
| Rate for Payer: Blue Shield of California EPN |
$60.25
|
| Rate for Payer: Cash Price |
$67.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$80.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$104.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$104.95
|
| Rate for Payer: Dignity Health Senior |
$104.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$79.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$76.43
|
| Rate for Payer: Heritage Provider Network Senior |
$76.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$58.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$86.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$86.43
|
| Rate for Payer: Multiplan Commercial |
$92.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$49.39
|
| Rate for Payer: TriValley Medical Group Senior |
$49.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$61.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$61.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$104.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$104.95
|
| Rate for Payer: Vantage Medical Group Senior |
$104.95
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
|
IP
|
$123.47
|
|
|
Service Code
|
NDC 0078-0469-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.35 |
| Max. Negotiated Rate |
$92.60 |
| Rate for Payer: Adventist Health Commercial |
$24.69
|
| Rate for Payer: Cash Price |
$67.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$83.59
|
| Rate for Payer: Heritage Provider Network Senior |
$83.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.87
|
| Rate for Payer: Multiplan Commercial |
$92.60
|
|
|
DEFERASIROX 360 MG TABLET [206428]
|
Facility
|
OP
|
$264.76
|
|
|
Service Code
|
NDC 0078-0656-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$47.92 |
| Max. Negotiated Rate |
$225.05 |
| Rate for Payer: Adventist Health Commercial |
$52.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$141.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$181.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$225.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$145.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$198.57
|
| Rate for Payer: Blue Shield of California Commercial |
$161.50
|
| Rate for Payer: Blue Shield of California EPN |
$129.20
|
| Rate for Payer: Cash Price |
$145.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$172.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$225.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$225.05
|
| Rate for Payer: Dignity Health Senior |
$225.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$169.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$163.89
|
| Rate for Payer: Heritage Provider Network Senior |
$163.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$126.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$185.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$185.33
|
| Rate for Payer: Multiplan Commercial |
$198.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$105.90
|
| Rate for Payer: TriValley Medical Group Senior |
$105.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$132.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$132.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$225.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$225.05
|
| Rate for Payer: Vantage Medical Group Senior |
$225.05
|
|
|
DEFERASIROX 360 MG TABLET [206428]
|
Facility
|
IP
|
$264.76
|
|
|
Service Code
|
NDC 0078-0656-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$47.92 |
| Max. Negotiated Rate |
$198.57 |
| Rate for Payer: Adventist Health Commercial |
$52.95
|
| Rate for Payer: Cash Price |
$145.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$142.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$179.24
|
| Rate for Payer: Heritage Provider Network Senior |
$179.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.19
|
| Rate for Payer: Multiplan Commercial |
$198.57
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
|
OP
|
$246.93
|
|
|
Service Code
|
NDC 0078-0470-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.69 |
| Max. Negotiated Rate |
$209.89 |
| Rate for Payer: Adventist Health Commercial |
$49.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$131.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$169.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$209.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$135.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$185.20
|
| Rate for Payer: Blue Shield of California Commercial |
$150.63
|
| Rate for Payer: Blue Shield of California EPN |
$120.50
|
| Rate for Payer: Cash Price |
$135.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$160.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$209.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$209.89
|
| Rate for Payer: Dignity Health Senior |
$209.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$158.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.85
|
| Rate for Payer: Heritage Provider Network Senior |
$152.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$117.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$172.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$172.85
|
| Rate for Payer: Multiplan Commercial |
$185.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$98.77
|
| Rate for Payer: TriValley Medical Group Senior |
$98.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$123.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$123.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$209.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$209.89
|
| Rate for Payer: Vantage Medical Group Senior |
$209.89
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
|
IP
|
$246.93
|
|
|
Service Code
|
NDC 0078-0470-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.69 |
| Max. Negotiated Rate |
$185.20 |
| Rate for Payer: Adventist Health Commercial |
$49.39
|
| Rate for Payer: Cash Price |
$135.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$167.17
|
| Rate for Payer: Heritage Provider Network Senior |
$167.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.73
|
| Rate for Payer: Multiplan Commercial |
$185.20
|
|
|
DEFERASIROX 90 MG TABLET [206426]
|
Facility
|
IP
|
$66.19
|
|
|
Service Code
|
NDC 0078-0654-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$49.64 |
| Rate for Payer: Adventist Health Commercial |
$13.24
|
| Rate for Payer: Cash Price |
$36.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.81
|
| Rate for Payer: Heritage Provider Network Senior |
$44.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.55
|
| Rate for Payer: Multiplan Commercial |
$49.64
|
|
|
DEFERASIROX 90 MG TABLET [206426]
|
Facility
|
OP
|
$66.19
|
|
|
Service Code
|
NDC 0078-0654-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: Adventist Health Commercial |
$13.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$35.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$45.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$56.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$36.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.64
|
| Rate for Payer: Blue Shield of California Commercial |
$40.38
|
| Rate for Payer: Blue Shield of California EPN |
$32.30
|
| Rate for Payer: Cash Price |
$36.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$43.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$56.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$56.26
|
| Rate for Payer: Dignity Health Senior |
$56.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.97
|
| Rate for Payer: Heritage Provider Network Senior |
$40.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$31.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$46.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$46.33
|
| Rate for Payer: Multiplan Commercial |
$49.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$26.48
|
| Rate for Payer: TriValley Medical Group Senior |
$26.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$33.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$56.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$56.26
|
| Rate for Payer: Vantage Medical Group Senior |
$56.26
|
|
