|
EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION [221921]
|
Facility
OP
|
$52.94
|
|
|
Service Code
|
CPT Q5106
|
| Hospital Charge Code |
NDG221921
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$39.70 |
| Rate for Payer: Adventist Health Commercial |
$10.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.78
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.61
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.59
|
| Rate for Payer: Blue Shield of California Commercial |
$11.25
|
| Rate for Payer: Blue Shield of California EPN |
$11.25
|
| Rate for Payer: Cash Price |
$23.82
|
| Rate for Payer: Cash Price |
$23.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.61
|
| Rate for Payer: Dignity Health Senior |
$8.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.88
|
| Rate for Payer: EPIC Health Plan Medicare |
$7.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.51
|
| Rate for Payer: Heritage Provider Network Senior |
$24.51
|
| Rate for Payer: Humana Medicare |
$7.82
|
| Rate for Payer: IEHP Medi-Cal |
$19.16
|
| Rate for Payer: IEHP Medicare Advantage |
$7.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.86
|
| Rate for Payer: Multiplan Commercial |
$39.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.61
|
| Rate for Payer: TriValley Medical Group Senior |
$7.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.61
|
| Rate for Payer: Vantage Medical Group Senior |
$7.82
|
|
|
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION [153307]
|
Facility
IP
|
$53.40
|
|
|
Service Code
|
CPT J1325
|
| Hospital Charge Code |
1771290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.67 |
| Max. Negotiated Rate |
$40.05 |
| Rate for Payer: Adventist Health Commercial |
$10.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.69
|
| Rate for Payer: Cash Price |
$24.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.15
|
| Rate for Payer: Heritage Provider Network Senior |
$36.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.35
|
| Rate for Payer: Multiplan Commercial |
$40.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.84
|
|
|
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION [153307]
|
Facility
OP
|
$59.02
|
|
|
Service Code
|
CPT J1325
|
| Hospital Charge Code |
NDC155307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.68 |
| Max. Negotiated Rate |
$50.17 |
| Rate for Payer: Adventist Health Commercial |
$11.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$50.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$44.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.94
|
| Rate for Payer: Blue Shield of California Commercial |
$17.41
|
| Rate for Payer: Blue Shield of California EPN |
$17.41
|
| Rate for Payer: Cash Price |
$26.56
|
| Rate for Payer: Cash Price |
$26.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.17
|
| Rate for Payer: Dignity Health Senior |
$50.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.33
|
| Rate for Payer: Heritage Provider Network Senior |
$27.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.76
|
| Rate for Payer: Multiplan Commercial |
$44.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.17
|
| Rate for Payer: Vantage Medical Group Senior |
$50.17
|
|
|
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION [153307]
|
Facility
OP
|
$53.40
|
|
|
Service Code
|
CPT J1325
|
| Hospital Charge Code |
1771290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.67 |
| Max. Negotiated Rate |
$45.39 |
| Rate for Payer: Adventist Health Commercial |
$10.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.69
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$45.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$29.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$40.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.94
|
| Rate for Payer: Blue Shield of California Commercial |
$17.41
|
| Rate for Payer: Blue Shield of California EPN |
$17.41
|
| Rate for Payer: Cash Price |
$24.03
|
| Rate for Payer: Cash Price |
$24.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$45.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.39
|
| Rate for Payer: Dignity Health Senior |
$45.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.72
|
| Rate for Payer: Heritage Provider Network Senior |
$24.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$25.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.35
|
| Rate for Payer: Multiplan Commercial |
$40.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.39
|
| Rate for Payer: Vantage Medical Group Senior |
$45.39
|
|
|
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION [153307]
|
Facility
IP
|
$59.02
|
|
|
Service Code
|
CPT J1325
|
| Hospital Charge Code |
NDC155307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.68 |
| Max. Negotiated Rate |
$44.26 |
| Rate for Payer: Adventist Health Commercial |
$11.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.55
|
| Rate for Payer: Cash Price |
$26.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.96
|
| Rate for Payer: Heritage Provider Network Senior |
$39.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.76
|
| Rate for Payer: Multiplan Commercial |
$44.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.72
|
|
|
EPOPROSTENOL (GLYCINE) 0.5 MG INTRAVENOUS SOLUTION [15897]
|
Facility
OP
|
$22.43
|
|
|
Service Code
|
CPT J1325
|
| Hospital Charge Code |
1759843
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$39.21 |
| Rate for Payer: Adventist Health Commercial |
$4.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.94
|
| Rate for Payer: Blue Shield of California Commercial |
$17.41
|
| Rate for Payer: Blue Shield of California EPN |
$17.41
|
| Rate for Payer: Cash Price |
$10.09
|
| Rate for Payer: Cash Price |
$10.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.07
|
| Rate for Payer: Dignity Health Senior |
$19.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.39
|
| Rate for Payer: Heritage Provider Network Senior |
$10.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.61
|
| Rate for Payer: Multiplan Commercial |
$16.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.07
|
| Rate for Payer: Vantage Medical Group Senior |
$19.07
|
|
|
EPOPROSTENOL (GLYCINE) 0.5 MG INTRAVENOUS SOLUTION [15897]
|
Facility
IP
|
$22.43
|
|
|
Service Code
|
CPT J1325
|
| Hospital Charge Code |
1759843
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$16.82 |
| Rate for Payer: Adventist Health Commercial |
$4.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.41
|
| Rate for Payer: Cash Price |
$10.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.19
|
| Rate for Payer: Heritage Provider Network Senior |
$15.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.61
|
| Rate for Payer: Multiplan Commercial |
$16.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.49
|
|
|
EPOPROSTENOL (GLYCINE) 1.5 MG INTRAVENOUS SOLUTION [15898]
|
Facility
IP
|
$54.17
|
|
|
Service Code
|
CPT J1325
|
| Hospital Charge Code |
1759954
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$40.63 |
| Rate for Payer: Adventist Health Commercial |
$10.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.21
|
| Rate for Payer: Cash Price |
$24.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.67
|
| Rate for Payer: Heritage Provider Network Senior |
$36.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.54
|
| Rate for Payer: Multiplan Commercial |
$40.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.10
|
|
|
EPOPROSTENOL (GLYCINE) 1.5 MG INTRAVENOUS SOLUTION [15898]
|
Facility
OP
|
$54.17
|
|
|
Service Code
|
CPT J1325
|
| Hospital Charge Code |
1759954
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$46.04 |
| Rate for Payer: Adventist Health Commercial |
$10.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$46.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$29.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$40.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.94
|
| Rate for Payer: Blue Shield of California Commercial |
$17.41
|
| Rate for Payer: Blue Shield of California EPN |
$17.41
|
| Rate for Payer: Cash Price |
$24.38
|
| Rate for Payer: Cash Price |
$24.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$46.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$46.04
|
| Rate for Payer: Dignity Health Senior |
$46.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.08
|
| Rate for Payer: Heritage Provider Network Senior |
$25.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.54
|
| Rate for Payer: Multiplan Commercial |
$40.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$46.04
|
| Rate for Payer: Vantage Medical Group Senior |
$46.04
|
|
|
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION [23123]
|
Facility
IP
|
$3.00
|
|
|
Service Code
|
CPT J1327
|
| Hospital Charge Code |
1722021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.13
|
|
|
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION [23123]
|
Facility
OP
|
$3.38
|
|
|
Service Code
|
CPT J1327
|
| Hospital Charge Code |
1722021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$272.05 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$42.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$42.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$42.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$272.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$272.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$272.05
|
| Rate for Payer: Blue Shield of California Commercial |
$13.77
|
| Rate for Payer: Blue Shield of California Commercial |
$13.77
|
| Rate for Payer: Blue Shield of California Commercial |
$13.77
|
| Rate for Payer: Blue Shield of California EPN |
$13.77
|
| Rate for Payer: Blue Shield of California EPN |
$13.77
|
| Rate for Payer: Blue Shield of California EPN |
$13.77
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.68
|
| Rate for Payer: Dignity Health Senior |
$3.68
|
| Rate for Payer: Dignity Health Senior |
$3.68
|
| Rate for Payer: Dignity Health Senior |
$3.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.56
|
| Rate for Payer: Heritage Provider Network Senior |
$1.56
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Humana Medicare |
$3.35
|
| Rate for Payer: Humana Medicare |
$3.35
|
| Rate for Payer: Humana Medicare |
$3.35
|
| Rate for Payer: IEHP Medicare Advantage |
$3.35
|
| Rate for Payer: IEHP Medicare Advantage |
$3.35
|
| Rate for Payer: IEHP Medicare Advantage |
$3.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.22
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.68
|
| Rate for Payer: TriValley Medical Group Senior |
$3.35
|
| Rate for Payer: TriValley Medical Group Senior |
$3.35
|
| Rate for Payer: TriValley Medical Group Senior |
$3.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.68
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]
|
Facility
IP
|
$6.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG23124
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.06
|
| Rate for Payer: Heritage Provider Network Senior |
$4.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.00
|
|
|
EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]
|
Facility
OP
|
$6.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG23124
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Blue Shield of California Commercial |
$3.73
|
| Rate for Payer: Blue Shield of California EPN |
$3.52
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Senior |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.78
|
| Rate for Payer: Heritage Provider Network Senior |
$2.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]
|
Facility
IP
|
$11.28
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1722020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$8.46 |
| Rate for Payer: Adventist Health Commercial |
$2.26
|
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.71
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.66
|
| Rate for Payer: Heritage Provider Network Senior |
$3.66
|
| Rate for Payer: Heritage Provider Network Senior |
$7.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$8.46
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.80
|
|
|
EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]
|
Facility
OP
|
$11.28
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1722020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$9.59 |
| Rate for Payer: Adventist Health Commercial |
$2.26
|
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.46
|
| Rate for Payer: Blue Shield of California Commercial |
$3.35
|
| Rate for Payer: Blue Shield of California Commercial |
$7.00
|
| Rate for Payer: Blue Shield of California EPN |
$3.17
|
| Rate for Payer: Blue Shield of California EPN |
$6.62
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.59
|
| Rate for Payer: Dignity Health Senior |
$4.59
|
| Rate for Payer: Dignity Health Senior |
$9.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$5.22
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$8.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.59
|
| Rate for Payer: Vantage Medical Group Senior |
$9.59
|
| Rate for Payer: Vantage Medical Group Senior |
$4.59
|
|
|
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION [222798]
|
Facility
OP
|
$68.40
|
|
|
Service Code
|
CPT J0122
|
| Hospital Charge Code |
ERX222798
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Adventist Health Commercial |
$13.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$46.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.10
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$30.78
|
| Rate for Payer: Cash Price |
$30.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: Dignity Health Senior |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.78
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.67
|
| Rate for Payer: Heritage Provider Network Senior |
$31.67
|
| Rate for Payer: Humana Medicare |
$1.48
|
| Rate for Payer: IEHP Medi-Cal |
$8.72
|
| Rate for Payer: IEHP Medicare Advantage |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.86
|
| Rate for Payer: Multiplan Commercial |
$51.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.63
|
| Rate for Payer: TriValley Medical Group Senior |
$1.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Vantage Medical Group Senior |
$1.48
|
|
|
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION [222798]
|
Facility
IP
|
$68.40
|
|
|
Service Code
|
CPT J0122
|
| Hospital Charge Code |
ERX222798
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Adventist Health Commercial |
$13.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$46.99
|
| Rate for Payer: Cash Price |
$30.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.31
|
| Rate for Payer: Heritage Provider Network Senior |
$46.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.10
|
| Rate for Payer: Multiplan Commercial |
$51.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.85
|
|
|
ERDAFITINIB 3 MG TABLET [224623]
|
Facility
IP
|
$403.73
|
|
|
Service Code
|
NDC 59676-030-56
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.08 |
| Max. Negotiated Rate |
$302.80 |
| Rate for Payer: Adventist Health Commercial |
$80.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$277.36
|
| Rate for Payer: Cash Price |
$181.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$185.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$218.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$273.33
|
| Rate for Payer: Heritage Provider Network Senior |
$273.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$73.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.93
|
| Rate for Payer: Multiplan Commercial |
$302.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$147.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$134.89
|
|
|
ERDAFITINIB 3 MG TABLET [224623]
|
Facility
OP
|
$403.73
|
|
|
Service Code
|
NDC 59676-030-56
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.08 |
| Max. Negotiated Rate |
$343.17 |
| Rate for Payer: Adventist Health Commercial |
$80.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$215.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$277.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$343.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$222.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$302.80
|
| Rate for Payer: Blue Shield of California Commercial |
$250.72
|
| Rate for Payer: Blue Shield of California EPN |
$236.99
|
| Rate for Payer: Cash Price |
$181.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$185.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$343.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$343.17
|
| Rate for Payer: Dignity Health Senior |
$343.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$258.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$186.93
|
| Rate for Payer: Heritage Provider Network Senior |
$186.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$194.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$73.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.93
|
| Rate for Payer: Multiplan Commercial |
$302.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$147.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$134.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$343.17
|
| Rate for Payer: Vantage Medical Group Senior |
$343.17
|
|
|
ERDAFITINIB 4 MG TABLET [224624]
|
Facility
OP
|
$538.30
|
|
|
Service Code
|
NDC 59676-040-28
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.43 |
| Max. Negotiated Rate |
$457.56 |
| Rate for Payer: Adventist Health Commercial |
$107.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$287.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$369.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$457.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$296.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$403.72
|
| Rate for Payer: Blue Shield of California Commercial |
$334.28
|
| Rate for Payer: Blue Shield of California EPN |
$315.98
|
| Rate for Payer: Cash Price |
$242.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$247.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$457.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$457.56
|
| Rate for Payer: Dignity Health Senior |
$457.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$344.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$249.23
|
| Rate for Payer: Heritage Provider Network Senior |
$249.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$259.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.58
|
| Rate for Payer: Multiplan Commercial |
$403.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$196.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$179.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$457.56
|
| Rate for Payer: Vantage Medical Group Senior |
$457.56
|
|
|
ERDAFITINIB 4 MG TABLET [224624]
|
Facility
IP
|
$538.30
|
|
|
Service Code
|
NDC 59676-040-28
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.43 |
| Max. Negotiated Rate |
$403.72 |
| Rate for Payer: Adventist Health Commercial |
$107.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$369.81
|
| Rate for Payer: Cash Price |
$242.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$247.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$290.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$364.43
|
| Rate for Payer: Heritage Provider Network Senior |
$364.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.58
|
| Rate for Payer: Multiplan Commercial |
$403.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$196.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$179.85
|
|
|
ERDAFITINIB 5 MG TABLET [224625]
|
Facility
IP
|
$672.88
|
|
|
Service Code
|
NDC 59676-050-28
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$121.79 |
| Max. Negotiated Rate |
$504.66 |
| Rate for Payer: Adventist Health Commercial |
$134.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$462.27
|
| Rate for Payer: Cash Price |
$302.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$309.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$363.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$455.54
|
| Rate for Payer: Heritage Provider Network Senior |
$455.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$121.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.22
|
| Rate for Payer: Multiplan Commercial |
$504.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$245.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$224.81
|
|
|
ERDAFITINIB 5 MG TABLET [224625]
|
Facility
OP
|
$672.88
|
|
|
Service Code
|
NDC 59676-050-28
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$121.79 |
| Max. Negotiated Rate |
$571.95 |
| Rate for Payer: Adventist Health Commercial |
$134.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$359.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$462.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$571.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$370.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$504.66
|
| Rate for Payer: Blue Shield of California Commercial |
$417.86
|
| Rate for Payer: Blue Shield of California EPN |
$394.98
|
| Rate for Payer: Cash Price |
$302.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$309.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$571.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$571.95
|
| Rate for Payer: Dignity Health Senior |
$571.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$430.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$311.54
|
| Rate for Payer: Heritage Provider Network Senior |
$311.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$324.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$121.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.22
|
| Rate for Payer: Multiplan Commercial |
$504.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$245.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$224.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$571.95
|
| Rate for Payer: Vantage Medical Group Senior |
$571.95
|
|
|
ERENUMAB-AOOE 70 MG/ML SUBCUTANEOUS AUTO-INJECTOR [221765]
|
Facility
OP
|
$885.43
|
|
|
Service Code
|
CPT J3590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.26 |
| Max. Negotiated Rate |
$752.62 |
| Rate for Payer: Adventist Health Commercial |
$177.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$473.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$608.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$752.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$486.99
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$664.07
|
| Rate for Payer: Blue Shield of California Commercial |
$549.85
|
| Rate for Payer: Blue Shield of California EPN |
$519.75
|
| Rate for Payer: Cash Price |
$398.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$407.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$752.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$752.62
|
| Rate for Payer: Dignity Health Senior |
$752.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$566.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$409.95
|
| Rate for Payer: Heritage Provider Network Senior |
$409.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$426.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$160.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$221.36
|
| Rate for Payer: Multiplan Commercial |
$664.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$322.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$295.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$752.62
|
| Rate for Payer: Vantage Medical Group Senior |
$752.62
|
|
|
ERENUMAB-AOOE 70 MG/ML SUBCUTANEOUS AUTO-INJECTOR [221765]
|
Facility
IP
|
$885.43
|
|
|
Service Code
|
CPT J3590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.26 |
| Max. Negotiated Rate |
$664.07 |
| Rate for Payer: Adventist Health Commercial |
$177.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$608.29
|
| Rate for Payer: Cash Price |
$398.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$407.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$478.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$599.44
|
| Rate for Payer: Heritage Provider Network Senior |
$599.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$160.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$221.36
|
| Rate for Payer: Multiplan Commercial |
$664.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$322.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$295.82
|
|
