|
SELENIUM SULFIDE 1 % SHAMPOO [38961]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0536-1995-53
|
| Hospital Charge Code |
1743730
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
SELENIUM SULFIDE 2.25 % SHAMPOO [40158]
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 42192-152-06
|
| Hospital Charge Code |
NDG40158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.45
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.45
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
SELENIUM SULFIDE 2.25 % SHAMPOO [40158]
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 42192-152-06
|
| Hospital Charge Code |
NDG40158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
SELEXIPAG 200 MCG TABLET [212415]
|
Facility
|
IP
|
$271.97
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
ERX212415
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$149.58 |
| Max. Negotiated Rate |
$217.58 |
| Rate for Payer: Cash Price |
$122.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$217.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$163.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$149.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$203.98
|
|
|
SELEXIPAG 200 MCG TABLET [212415]
|
Facility
|
OP
|
$271.97
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
ERX212415
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$149.58 |
| Max. Negotiated Rate |
$203.98 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$163.18
|
| Rate for Payer: Aetna of CA Government/Medicare |
$163.18
|
| Rate for Payer: Cash Price |
$122.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$163.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$163.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$149.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$203.98
|
|
|
SELEXIPAG 400 MCG TABLET [212416]
|
Facility
|
OP
|
$422.95
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
ERX212416
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$232.62 |
| Max. Negotiated Rate |
$317.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$253.77
|
| Rate for Payer: Aetna of CA Government/Medicare |
$253.77
|
| Rate for Payer: Cash Price |
$190.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$253.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$253.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$232.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$317.21
|
|
|
SELEXIPAG 400 MCG TABLET [212416]
|
Facility
|
IP
|
$422.95
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
ERX212416
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$232.62 |
| Max. Negotiated Rate |
$338.36 |
| Rate for Payer: Cash Price |
$190.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$338.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$253.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$232.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$317.21
|
|
|
SELPERCATINIB 40 MG CAPSULE [228076]
|
Facility
|
OP
|
$141.46
|
|
|
Service Code
|
NDC 0002-3977-60
|
| Hospital Charge Code |
ERX228076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$77.80 |
| Max. Negotiated Rate |
$106.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$84.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$84.88
|
| Rate for Payer: Cash Price |
$63.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$84.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$84.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.80
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$106.10
|
|
|
SELPERCATINIB 40 MG CAPSULE [228076]
|
Facility
|
IP
|
$141.46
|
|
|
Service Code
|
NDC 0002-3977-60
|
| Hospital Charge Code |
ERX228076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$77.80 |
| Max. Negotiated Rate |
$113.17 |
| Rate for Payer: Cash Price |
$63.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$113.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$84.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.80
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$106.10
|
|
|
SELPERCATINIB 80 MG CAPSULE [228077]
|
Facility
|
IP
|
$212.18
|
|
|
Service Code
|
NDC 0002-2980-60
|
| Hospital Charge Code |
ERX228077
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$116.70 |
| Max. Negotiated Rate |
$169.74 |
| Rate for Payer: Cash Price |
$95.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$169.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$127.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$159.14
|
|
|
SELPERCATINIB 80 MG CAPSULE [228077]
|
Facility
|
IP
|
$212.18
|
|
|
Service Code
|
NDC 0002-2980-26
|
| Hospital Charge Code |
ERX228077
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$116.70 |
| Max. Negotiated Rate |
$169.74 |
| Rate for Payer: Cash Price |
$95.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$169.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$127.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$159.14
|
|
|
SELPERCATINIB 80 MG CAPSULE [228077]
|
Facility
|
OP
|
$212.18
|
|
|
Service Code
|
NDC 0002-2980-26
|
| Hospital Charge Code |
ERX228077
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$116.70 |
| Max. Negotiated Rate |
$159.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$127.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$127.31
|
| Rate for Payer: Cash Price |
$95.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$127.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$127.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$159.14
|
|
|
SELPERCATINIB 80 MG CAPSULE [228077]
|
Facility
|
OP
|
$212.18
|
|
|
Service Code
|
NDC 0002-2980-60
|
| Hospital Charge Code |
ERX228077
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$116.70 |
| Max. Negotiated Rate |
$159.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$127.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$127.31
|
| Rate for Payer: Cash Price |
$95.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$127.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$127.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$159.14
|
|
|
SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP [117388]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 121072208
|
| Hospital Charge Code |
NDG117388
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP [117388]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 121072208
|
| Hospital Charge Code |
NDG117388
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 60687-622-01
|
| Hospital Charge Code |
1710268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 46122-669-78
|
| Hospital Charge Code |
1710268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 69618-065-01
|
| Hospital Charge Code |
1710268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 0536-1248-01
|
| Hospital Charge Code |
1710268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 60687-622-11
|
| Hospital Charge Code |
1710268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 0536-1248-01
|
| Hospital Charge Code |
1710268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 67618-110-60
|
| Hospital Charge Code |
1710268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 69618-065-01
|
| Hospital Charge Code |
1710268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 57896-555-01
|
| Hospital Charge Code |
1710268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 57896-555-01
|
| Hospital Charge Code |
1710268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
