|
EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION [221920]
|
Facility
|
IP
|
$41.69
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.55 |
| Max. Negotiated Rate |
$31.27 |
| Rate for Payer: Adventist Health Commercial |
$8.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.85
|
| Rate for Payer: Cash Price |
$18.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.30
|
| Rate for Payer: Heritage Provider Network Senior |
$19.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.42
|
| Rate for Payer: Multiplan Commercial |
$31.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.80
|
|
|
EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION [221920]
|
Facility
|
OP
|
$41.69
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.55 |
| Max. Negotiated Rate |
$31.27 |
| Rate for Payer: Adventist Health Commercial |
$8.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.76
|
| 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 |
$18.76
|
| Rate for Payer: Cash Price |
$18.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.68
|
| Rate for Payer: EPIC Health Plan Medicare |
$7.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.30
|
| Rate for Payer: Heritage Provider Network Senior |
$19.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$19.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.68
|
| Rate for Payer: Multiplan Commercial |
$31.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.68
|
| Rate for Payer: TriValley Medical Group Senior |
$16.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.77
|
| Rate for Payer: Vantage Medical Group Senior |
$8.77
|
|
|
EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [221923]
|
Facility
|
OP
|
$555.81
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.97 |
| Max. Negotiated Rate |
$416.86 |
| Rate for Payer: Adventist Health Commercial |
$111.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$343.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.76
|
| 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 |
$250.11
|
| Rate for Payer: Cash Price |
$250.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$255.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$355.72
|
| Rate for Payer: EPIC Health Plan Medicare |
$7.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$257.34
|
| Rate for Payer: Heritage Provider Network Senior |
$257.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$265.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$100.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$138.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.68
|
| Rate for Payer: Multiplan Commercial |
$416.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$222.32
|
| Rate for Payer: TriValley Medical Group Senior |
$222.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$200.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$184.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.77
|
| Rate for Payer: Vantage Medical Group Senior |
$8.77
|
|
|
EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [221923]
|
Facility
|
IP
|
$555.81
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.60 |
| Max. Negotiated Rate |
$416.86 |
| Rate for Payer: Adventist Health Commercial |
$111.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$357.94
|
| Rate for Payer: Cash Price |
$250.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$255.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$300.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$257.34
|
| Rate for Payer: Heritage Provider Network Senior |
$257.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$100.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$138.95
|
| Rate for Payer: Multiplan Commercial |
$416.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$200.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$184.03
|
|
|
EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION [221921]
|
Facility
|
IP
|
$55.58
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$41.69 |
| Rate for Payer: Adventist Health Commercial |
$11.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.79
|
| Rate for Payer: Cash Price |
$25.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.73
|
| Rate for Payer: Heritage Provider Network Senior |
$25.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.89
|
| Rate for Payer: Multiplan Commercial |
$41.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.40
|
|
|
EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION [221921]
|
Facility
|
OP
|
$55.58
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
901700041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.97 |
| Max. Negotiated Rate |
$41.69 |
| Rate for Payer: Adventist Health Commercial |
$11.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.76
|
| 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 |
$25.01
|
| Rate for Payer: Cash Price |
$25.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.57
|
| Rate for Payer: EPIC Health Plan Medicare |
$7.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.73
|
| Rate for Payer: Heritage Provider Network Senior |
$25.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$26.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.68
|
| Rate for Payer: Multiplan Commercial |
$41.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.23
|
| Rate for Payer: TriValley Medical Group Senior |
$22.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.77
|
| Rate for Payer: Vantage Medical Group Senior |
$8.77
|
|
|
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION [153307]
|
Facility
|
IP
|
$53.40
|
|
|
Service Code
|
HCPCS J1325
|
| Hospital Charge Code |
901700025
|
|
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: Adventist Health Commercial |
$14.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$45.27
|
| Rate for Payer: Cash Price |
$24.03
|
| Rate for Payer: Cash Price |
$31.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.55
|
| Rate for Payer: Heritage Provider Network Senior |
$32.55
|
| Rate for Payer: Heritage Provider Network Senior |
$24.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.57
|
| Rate for Payer: Multiplan Commercial |
$40.05
|
| Rate for Payer: Multiplan Commercial |
$52.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$25.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.68
|
|
|
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION [153307]
|
Facility
|
OP
|
$53.40
|
|
|
Service Code
|
HCPCS J1325
|
| Hospital Charge Code |
901700025
|
|
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: Adventist Health Commercial |
$14.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$45.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$59.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$29.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$40.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$52.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.49
|
| Rate for Payer: Blue Shield of California Commercial |
$19.07
|
| Rate for Payer: Blue Shield of California Commercial |
$19.07
|
| Rate for Payer: Blue Shield of California EPN |
$19.07
|
| Rate for Payer: Blue Shield of California EPN |
$19.07
|
| Rate for Payer: Cash Price |
$24.03
|
| Rate for Payer: Cash Price |
$31.64
|
| Rate for Payer: Cash Price |
$24.03
|
| Rate for Payer: Cash Price |
$31.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$45.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$59.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$45.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$59.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.72
|
| Rate for Payer: Heritage Provider Network Senior |
$32.55
|
| Rate for Payer: Heritage Provider Network Senior |
$24.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$25.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$33.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$49.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$37.38
|
| Rate for Payer: Multiplan Commercial |
$52.73
|
| Rate for Payer: Multiplan Commercial |
$40.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$21.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$28.12
|
| Rate for Payer: TriValley Medical Group Senior |
$21.36
|
| Rate for Payer: TriValley Medical Group Senior |
$28.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$25.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$59.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$45.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$59.76
|
| Rate for Payer: Vantage Medical Group Senior |
$59.76
|
| Rate for Payer: Vantage Medical Group Senior |
$45.39
|
|
|
EPOPROSTENOL (GLYCINE) 0.5 MG INTRAVENOUS SOLUTION [15897]
|
Facility
|
IP
|
$22.43
|
|
|
Service Code
|
HCPCS J1325
|
| Hospital Charge Code |
901700025
|
|
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 |
$14.44
|
| 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 |
$10.39
|
| Rate for Payer: Heritage Provider Network Senior |
$10.39
|
| Rate for Payer: Kaiser Foundation Hospitals 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 |
$8.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.43
|
|
|
EPOPROSTENOL (GLYCINE) 0.5 MG INTRAVENOUS SOLUTION [15897]
|
Facility
|
OP
|
$22.43
|
|
|
Service Code
|
HCPCS J1325
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$38.49 |
| Rate for Payer: Adventist Health Commercial |
$4.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.49
|
| Rate for Payer: Blue Shield of California Commercial |
$19.07
|
| Rate for Payer: Blue Shield of California EPN |
$19.07
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$10.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15.70
|
| Rate for Payer: Multiplan Commercial |
$16.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.97
|
| Rate for Payer: TriValley Medical Group Senior |
$8.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.07
|
| Rate for Payer: Vantage Medical Group Senior |
$19.07
|
|
|
EPOPROSTENOL (GLYCINE) 1.5 MG INTRAVENOUS SOLUTION [15898]
|
Facility
|
OP
|
$54.17
|
|
|
Service Code
|
HCPCS J1325
|
| Hospital Charge Code |
901700025
|
|
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 Non-Gatekeeper |
$33.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$46.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$29.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$40.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.49
|
| Rate for Payer: Blue Shield of California Commercial |
$19.07
|
| Rate for Payer: Blue Shield of California EPN |
$19.07
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$25.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$37.92
|
| Rate for Payer: Multiplan Commercial |
$40.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$21.67
|
| Rate for Payer: TriValley Medical Group Senior |
$21.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$46.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$46.04
|
| Rate for Payer: Vantage Medical Group Senior |
$46.04
|
|
|
EPOPROSTENOL (GLYCINE) 1.5 MG INTRAVENOUS SOLUTION [15898]
|
Facility
|
IP
|
$54.17
|
|
|
Service Code
|
HCPCS J1325
|
| Hospital Charge Code |
901700025
|
|
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 |
$34.89
|
| 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 |
$25.08
|
| Rate for Payer: Heritage Provider Network Senior |
$25.08
|
| Rate for Payer: Kaiser Foundation Hospitals 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 |
$19.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.94
|
|
|
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION [23123]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
HCPCS J1327
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$308.59 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$308.59
|
| Rate for Payer: Blue Shield of California Commercial |
$10.84
|
| Rate for Payer: Blue Shield of California EPN |
$10.84
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.19
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.26
|
| Rate for Payer: Vantage Medical Group Senior |
$3.87
|
|
|
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION [23123]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
HCPCS J1327
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.16
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
|
|
EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]
|
Facility
|
OP
|
$11.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
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 Non-Gatekeeper |
$6.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.46
|
| Rate for Payer: Blue Shield of California Commercial |
$6.88
|
| Rate for Payer: Blue Shield of California Commercial |
$3.29
|
| Rate for Payer: Blue Shield of California EPN |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$5.50
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| 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 Medicare Advantage |
$4.59
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| 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 Foundation Hospitals Commercial |
$5.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.04
|
| Rate for Payer: Kaiser Foundation Hospitals 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: Molina Healthcare of CA Medi-Cal/Medicare |
$3.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7.90
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$8.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.16
|
| Rate for Payer: TriValley Medical Group Senior |
$4.51
|
| Rate for Payer: TriValley Medical Group Senior |
$2.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$9.59
|
|
|
EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J1327
|
| Hospital Charge Code |
901700025
|
|
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 |
$3.86
|
| 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 |
$2.78
|
| Rate for Payer: Heritage Provider Network Senior |
$2.78
|
| Rate for Payer: Kaiser Foundation Hospitals 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 |
$2.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.99
|
|
|
EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J1327
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$308.59 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$308.59
|
| Rate for Payer: Blue Shield of California Commercial |
$10.84
|
| Rate for Payer: Blue Shield of California EPN |
$10.84
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.78
|
| Rate for Payer: Heritage Provider Network Senior |
$2.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.19
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Senior |
$2.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.26
|
| Rate for Payer: Vantage Medical Group Senior |
$3.87
|
|
|
EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]
|
Facility
|
IP
|
$5.40
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Adventist Health Commercial |
$2.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.48
|
| 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 |
$5.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$5.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.04
|
| Rate for Payer: Kaiser Foundation Hospitals 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 |
$1.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.73
|
|
|
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION [222798]
|
Facility
|
IP
|
$87.50
|
|
|
Service Code
|
HCPCS J0122
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.84 |
| Max. Negotiated Rate |
$65.62 |
| Rate for Payer: Adventist Health Commercial |
$17.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.35
|
| Rate for Payer: Cash Price |
$39.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.51
|
| Rate for Payer: Heritage Provider Network Senior |
$40.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.88
|
| Rate for Payer: Multiplan Commercial |
$65.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$31.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.97
|
|
|
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION [222798]
|
Facility
|
OP
|
$87.50
|
|
|
Service Code
|
HCPCS J0122
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$65.62 |
| Rate for Payer: Adventist Health Commercial |
$17.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.38
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Cash Price |
$39.38
|
| Rate for Payer: Cash Price |
$39.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.51
|
| Rate for Payer: Heritage Provider Network Senior |
$40.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$41.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$65.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$35.00
|
| Rate for Payer: TriValley Medical Group Senior |
$35.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$31.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.52
|
| Rate for Payer: Vantage Medical Group Senior |
$1.38
|
|
|
ERDAFITINIB 3 MG TABLET [224623]
|
Facility
|
OP
|
$466.66
|
|
|
Service Code
|
NDC 5967603056
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$84.47 |
| Max. Negotiated Rate |
$396.66 |
| Rate for Payer: Adventist Health Commercial |
$93.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$288.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$396.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$256.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$350.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$233.42
|
| Rate for Payer: Blue Shield of California Commercial |
$284.66
|
| Rate for Payer: Blue Shield of California EPN |
$227.73
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$303.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$396.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$396.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$396.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$298.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$288.86
|
| Rate for Payer: Heritage Provider Network Senior |
$288.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$222.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$84.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$326.66
|
| Rate for Payer: Multiplan Commercial |
$350.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$186.66
|
| Rate for Payer: TriValley Medical Group Senior |
$186.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$233.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$233.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$396.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$396.66
|
| Rate for Payer: Vantage Medical Group Senior |
$396.66
|
|
|
ERDAFITINIB 3 MG TABLET [224623]
|
Facility
|
IP
|
$466.66
|
|
|
Service Code
|
NDC 5967603056
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$84.47 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Adventist Health Commercial |
$93.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$300.53
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$252.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$315.93
|
| Rate for Payer: Heritage Provider Network Senior |
$315.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$84.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.67
|
| Rate for Payer: Multiplan Commercial |
$350.00
|
|
|
ERDAFITINIB 4 MG TABLET [224624]
|
Facility
|
OP
|
$622.22
|
|
|
Service Code
|
NDC 5967604028
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$112.62 |
| Max. Negotiated Rate |
$528.89 |
| Rate for Payer: Adventist Health Commercial |
$124.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$384.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$528.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$342.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$466.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$311.23
|
| Rate for Payer: Blue Shield of California Commercial |
$379.55
|
| Rate for Payer: Blue Shield of California EPN |
$303.64
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$404.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$528.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$528.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$528.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$398.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$385.15
|
| Rate for Payer: Heritage Provider Network Senior |
$385.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$296.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$112.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$435.55
|
| Rate for Payer: Multiplan Commercial |
$466.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$248.89
|
| Rate for Payer: TriValley Medical Group Senior |
$248.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$311.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$311.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$528.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$528.89
|
| Rate for Payer: Vantage Medical Group Senior |
$528.89
|
|
|
ERDAFITINIB 4 MG TABLET [224624]
|
Facility
|
IP
|
$622.22
|
|
|
Service Code
|
NDC 5967604028
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$112.62 |
| Max. Negotiated Rate |
$466.67 |
| Rate for Payer: Adventist Health Commercial |
$124.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$400.71
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$336.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$421.24
|
| Rate for Payer: Heritage Provider Network Senior |
$421.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$112.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.56
|
| Rate for Payer: Multiplan Commercial |
$466.67
|
|
|
ERDAFITINIB 5 MG TABLET [224625]
|
Facility
|
IP
|
$777.78
|
|
|
Service Code
|
NDC 5967605028
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$140.78 |
| Max. Negotiated Rate |
$583.34 |
| Rate for Payer: Adventist Health Commercial |
$155.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$500.89
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$420.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$526.56
|
| Rate for Payer: Heritage Provider Network Senior |
$526.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$140.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$194.44
|
| Rate for Payer: Multiplan Commercial |
$583.34
|
|
