|
SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]
|
Facility
|
IP
|
$300.49
|
|
|
Service Code
|
CPT Q2043
|
| Hospital Charge Code |
1753491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.12 |
| Max. Negotiated Rate |
$255.42 |
| Rate for Payer: Blue Shield of California Commercial |
$213.95
|
| Rate for Payer: Blue Shield of California EPN |
$153.85
|
| Rate for Payer: Cash Price |
$135.22
|
| Rate for Payer: Cigna of CA HMO |
$210.34
|
| Rate for Payer: Cigna of CA PPO |
$210.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$120.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$120.20
|
| Rate for Payer: Galaxy Health WC |
$255.42
|
| Rate for Payer: Global Benefits Group Commercial |
$180.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$200.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$114.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.12
|
| Rate for Payer: Multiplan Commercial |
$240.39
|
| Rate for Payer: Networks By Design Commercial |
$150.24
|
| Rate for Payer: Prime Health Services Commercial |
$255.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$113.47
|
| Rate for Payer: United Healthcare All Other HMO |
$110.82
|
| Rate for Payer: United Healthcare HMO Rider |
$108.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$99.16
|
|
|
SIROLIMUS 0.5 MG TABLET [104764]
|
Facility
|
OP
|
$20.63
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1712518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$37.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.40
|
| Rate for Payer: Blue Distinction Transplant |
$3.93
|
| Rate for Payer: Blue Distinction Transplant |
$6.21
|
| Rate for Payer: Blue Distinction Transplant |
$12.38
|
| Rate for Payer: Blue Shield of California Commercial |
$15.20
|
| Rate for Payer: Blue Shield of California Commercial |
$7.63
|
| Rate for Payer: Blue Shield of California Commercial |
$4.83
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna of CA HMO |
$4.58
|
| Rate for Payer: Cigna of CA HMO |
$14.44
|
| Rate for Payer: Cigna of CA HMO |
$7.24
|
| Rate for Payer: Cigna of CA PPO |
$4.58
|
| Rate for Payer: Cigna of CA PPO |
$14.44
|
| Rate for Payer: Cigna of CA PPO |
$7.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.80
|
| Rate for Payer: Dignity Health Media |
$8.80
|
| Rate for Payer: Dignity Health Media |
$17.54
|
| Rate for Payer: Dignity Health Media |
$5.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.62
|
| Rate for Payer: Galaxy Health WC |
$5.57
|
| Rate for Payer: Galaxy Health WC |
$17.54
|
| Rate for Payer: Galaxy Health WC |
$8.80
|
| Rate for Payer: Global Benefits Group Commercial |
$3.93
|
| Rate for Payer: Global Benefits Group Commercial |
$12.38
|
| Rate for Payer: Global Benefits Group Commercial |
$6.21
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.91
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$15.47
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$7.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$8.28
|
| Rate for Payer: Multiplan Commercial |
$16.50
|
| Rate for Payer: Networks By Design Commercial |
$3.28
|
| Rate for Payer: Networks By Design Commercial |
$5.18
|
| Rate for Payer: Networks By Design Commercial |
$10.32
|
| Rate for Payer: Prime Health Services Commercial |
$8.80
|
| Rate for Payer: Prime Health Services Commercial |
$5.57
|
| Rate for Payer: Prime Health Services Commercial |
$17.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.18
|
| Rate for Payer: United Healthcare All Other HMO |
$3.28
|
| Rate for Payer: United Healthcare All Other HMO |
$10.32
|
| Rate for Payer: United Healthcare All Other HMO |
$5.18
|
| Rate for Payer: United Healthcare HMO Rider |
$5.18
|
| Rate for Payer: United Healthcare HMO Rider |
$3.28
|
| Rate for Payer: United Healthcare HMO Rider |
$10.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.80
|
| Rate for Payer: Vantage Medical Group Senior |
$5.57
|
| Rate for Payer: Vantage Medical Group Senior |
$8.80
|
| Rate for Payer: Vantage Medical Group Senior |
$17.54
|
|
|
SIROLIMUS 0.5 MG TABLET [104764]
|
Facility
|
IP
|
$10.35
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1712518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$8.80 |
| Rate for Payer: Blue Shield of California Commercial |
$7.37
|
| Rate for Payer: Blue Shield of California Commercial |
$14.69
|
| Rate for Payer: Blue Shield of California Commercial |
$4.66
|
| Rate for Payer: Blue Shield of California EPN |
$10.56
|
| Rate for Payer: Blue Shield of California EPN |
$3.35
|
| Rate for Payer: Blue Shield of California EPN |
$5.30
|
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cigna of CA HMO |
$4.58
|
| Rate for Payer: Cigna of CA HMO |
$14.44
|
| Rate for Payer: Cigna of CA HMO |
$7.24
|
| Rate for Payer: Cigna of CA PPO |
$7.24
|
| Rate for Payer: Cigna of CA PPO |
$14.44
|
| Rate for Payer: Cigna of CA PPO |
$4.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.25
|
| Rate for Payer: Galaxy Health WC |
$17.54
|
| Rate for Payer: Galaxy Health WC |
$8.80
|
| Rate for Payer: Galaxy Health WC |
$5.57
|
| Rate for Payer: Global Benefits Group Commercial |
$3.93
|
| Rate for Payer: Global Benefits Group Commercial |
$6.21
|
| Rate for Payer: Global Benefits Group Commercial |
$12.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$8.28
|
| Rate for Payer: Multiplan Commercial |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Networks By Design Commercial |
$10.32
|
| Rate for Payer: Networks By Design Commercial |
$5.18
|
| Rate for Payer: Networks By Design Commercial |
$3.28
|
| Rate for Payer: Prime Health Services Commercial |
$8.80
|
| Rate for Payer: Prime Health Services Commercial |
$17.54
|
| Rate for Payer: Prime Health Services Commercial |
$5.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.91
|
| Rate for Payer: United Healthcare All Other HMO |
$7.61
|
| Rate for Payer: United Healthcare All Other HMO |
$3.82
|
| Rate for Payer: United Healthcare All Other HMO |
$2.42
|
| Rate for Payer: United Healthcare HMO Rider |
$2.36
|
| Rate for Payer: United Healthcare HMO Rider |
$3.73
|
| Rate for Payer: United Healthcare HMO Rider |
$7.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.16
|
|
|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
|
IP
|
$17.50
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1715200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$14.88 |
| Rate for Payer: Blue Shield of California Commercial |
$12.46
|
| Rate for Payer: Blue Shield of California Commercial |
$14.99
|
| Rate for Payer: Blue Shield of California EPN |
$8.96
|
| Rate for Payer: Blue Shield of California EPN |
$10.78
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cigna of CA HMO |
$12.25
|
| Rate for Payer: Cigna of CA HMO |
$14.74
|
| Rate for Payer: Cigna of CA PPO |
$14.74
|
| Rate for Payer: Cigna of CA PPO |
$12.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.42
|
| Rate for Payer: Galaxy Health WC |
$14.88
|
| Rate for Payer: Galaxy Health WC |
$17.89
|
| Rate for Payer: Global Benefits Group Commercial |
$12.63
|
| Rate for Payer: Global Benefits Group Commercial |
$10.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.05
|
| Rate for Payer: Multiplan Commercial |
$14.00
|
| Rate for Payer: Multiplan Commercial |
$16.84
|
| Rate for Payer: Networks By Design Commercial |
$8.75
|
| Rate for Payer: Networks By Design Commercial |
$10.52
|
| Rate for Payer: Prime Health Services Commercial |
$14.88
|
| Rate for Payer: Prime Health Services Commercial |
$17.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.95
|
| Rate for Payer: United Healthcare All Other HMO |
$6.45
|
| Rate for Payer: United Healthcare All Other HMO |
$7.76
|
| Rate for Payer: United Healthcare HMO Rider |
$6.31
|
| Rate for Payer: United Healthcare HMO Rider |
$7.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.95
|
|
|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
|
OP
|
$21.05
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1715200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.05 |
| Max. Negotiated Rate |
$37.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.40
|
| Rate for Payer: Blue Distinction Transplant |
$12.63
|
| Rate for Payer: Blue Distinction Transplant |
$10.50
|
| Rate for Payer: Blue Shield of California Commercial |
$12.90
|
| Rate for Payer: Blue Shield of California Commercial |
$15.51
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cigna of CA HMO |
$14.74
|
| Rate for Payer: Cigna of CA HMO |
$12.25
|
| Rate for Payer: Cigna of CA PPO |
$14.74
|
| Rate for Payer: Cigna of CA PPO |
$12.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.89
|
| Rate for Payer: Dignity Health Media |
$17.89
|
| Rate for Payer: Dignity Health Media |
$14.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.42
|
| Rate for Payer: Galaxy Health WC |
$17.89
|
| Rate for Payer: Galaxy Health WC |
$14.88
|
| Rate for Payer: Global Benefits Group Commercial |
$10.50
|
| Rate for Payer: Global Benefits Group Commercial |
$12.63
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$13.12
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$15.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.05
|
| Rate for Payer: Multiplan Commercial |
$16.84
|
| Rate for Payer: Multiplan Commercial |
$14.00
|
| Rate for Payer: Networks By Design Commercial |
$8.75
|
| Rate for Payer: Networks By Design Commercial |
$10.52
|
| Rate for Payer: Prime Health Services Commercial |
$17.89
|
| Rate for Payer: Prime Health Services Commercial |
$14.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.52
|
| Rate for Payer: United Healthcare All Other HMO |
$10.52
|
| Rate for Payer: United Healthcare All Other HMO |
$8.75
|
| Rate for Payer: United Healthcare HMO Rider |
$10.52
|
| Rate for Payer: United Healthcare HMO Rider |
$8.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.89
|
| Rate for Payer: Vantage Medical Group Senior |
$17.89
|
| Rate for Payer: Vantage Medical Group Senior |
$14.88
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
|
IP
|
$16.66
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1711808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$14.16 |
| Rate for Payer: Blue Shield of California Commercial |
$11.86
|
| Rate for Payer: Blue Shield of California Commercial |
$6.41
|
| Rate for Payer: Blue Shield of California EPN |
$8.53
|
| Rate for Payer: Blue Shield of California EPN |
$4.61
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO |
$11.66
|
| Rate for Payer: Cigna of CA HMO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$11.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.60
|
| Rate for Payer: Galaxy Health WC |
$14.16
|
| Rate for Payer: Galaxy Health WC |
$7.65
|
| Rate for Payer: Global Benefits Group Commercial |
$5.40
|
| Rate for Payer: Global Benefits Group Commercial |
$10.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.16
|
| Rate for Payer: Multiplan Commercial |
$13.33
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: Networks By Design Commercial |
$8.33
|
| Rate for Payer: Networks By Design Commercial |
$4.50
|
| Rate for Payer: Prime Health Services Commercial |
$14.16
|
| Rate for Payer: Prime Health Services Commercial |
$7.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.40
|
| Rate for Payer: United Healthcare All Other HMO |
$6.14
|
| Rate for Payer: United Healthcare All Other HMO |
$3.32
|
| Rate for Payer: United Healthcare HMO Rider |
$6.01
|
| Rate for Payer: United Healthcare HMO Rider |
$3.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.97
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1711808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$37.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.40
|
| Rate for Payer: Blue Distinction Transplant |
$5.40
|
| Rate for Payer: Blue Distinction Transplant |
$10.00
|
| Rate for Payer: Blue Shield of California Commercial |
$12.28
|
| Rate for Payer: Blue Shield of California Commercial |
$6.63
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO |
$6.30
|
| Rate for Payer: Cigna of CA HMO |
$11.66
|
| Rate for Payer: Cigna of CA PPO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$11.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.65
|
| Rate for Payer: Dignity Health Media |
$7.65
|
| Rate for Payer: Dignity Health Media |
$14.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.60
|
| Rate for Payer: Galaxy Health WC |
$7.65
|
| Rate for Payer: Galaxy Health WC |
$14.16
|
| Rate for Payer: Global Benefits Group Commercial |
$10.00
|
| Rate for Payer: Global Benefits Group Commercial |
$5.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$12.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.16
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: Multiplan Commercial |
$13.33
|
| Rate for Payer: Networks By Design Commercial |
$8.33
|
| Rate for Payer: Networks By Design Commercial |
$4.50
|
| Rate for Payer: Prime Health Services Commercial |
$7.65
|
| Rate for Payer: Prime Health Services Commercial |
$14.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$8.33
|
| Rate for Payer: United Healthcare HMO Rider |
$4.50
|
| Rate for Payer: United Healthcare HMO Rider |
$8.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.65
|
| Rate for Payer: Vantage Medical Group Senior |
$7.65
|
| Rate for Payer: Vantage Medical Group Senior |
$14.16
|
|
|
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION [233123]
|
Facility
|
OP
|
$8,512.06
|
|
|
Service Code
|
NDC 80803-153-50
|
| Hospital Charge Code |
ERX233123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,042.89 |
| Max. Negotiated Rate |
$7,235.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5,583.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,235.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,681.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,681.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,071.49
|
| Rate for Payer: Blue Distinction Transplant |
$5,107.24
|
| Rate for Payer: Blue Shield of California Commercial |
$6,273.39
|
| Rate for Payer: Blue Shield of California EPN |
$4,971.04
|
| Rate for Payer: Cash Price |
$3,830.43
|
| Rate for Payer: Cigna of CA HMO |
$5,958.44
|
| Rate for Payer: Cigna of CA PPO |
$5,958.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,235.25
|
| Rate for Payer: Dignity Health Media |
$7,235.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,235.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,404.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,404.82
|
| Rate for Payer: Galaxy Health WC |
$7,235.25
|
| Rate for Payer: Global Benefits Group Commercial |
$5,107.24
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6,384.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,677.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,243.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,042.89
|
| Rate for Payer: Multiplan Commercial |
$6,809.65
|
| Rate for Payer: Networks By Design Commercial |
$4,256.03
|
| Rate for Payer: Prime Health Services Commercial |
$7,235.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5,107.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5,107.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,256.03
|
| Rate for Payer: United Healthcare All Other HMO |
$4,256.03
|
| Rate for Payer: United Healthcare HMO Rider |
$4,256.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,256.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,235.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,235.25
|
| Rate for Payer: Vantage Medical Group Senior |
$7,235.25
|
|
|
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION [233123]
|
Facility
|
IP
|
$8,512.06
|
|
|
Service Code
|
NDC 80803-153-50
|
| Hospital Charge Code |
ERX233123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,042.89 |
| Max. Negotiated Rate |
$7,235.25 |
| Rate for Payer: Blue Shield of California Commercial |
$6,060.59
|
| Rate for Payer: Blue Shield of California EPN |
$4,358.17
|
| Rate for Payer: Cash Price |
$3,830.43
|
| Rate for Payer: Cigna of CA HMO |
$5,958.44
|
| Rate for Payer: Cigna of CA PPO |
$5,958.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,404.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,404.82
|
| Rate for Payer: Galaxy Health WC |
$7,235.25
|
| Rate for Payer: Global Benefits Group Commercial |
$5,107.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,677.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,243.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,042.89
|
| Rate for Payer: Multiplan Commercial |
$6,809.65
|
| Rate for Payer: Networks By Design Commercial |
$4,256.03
|
| Rate for Payer: Prime Health Services Commercial |
$7,235.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,214.15
|
| Rate for Payer: United Healthcare All Other HMO |
$3,139.25
|
| Rate for Payer: United Healthcare HMO Rider |
$3,071.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,808.98
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0277-01
|
| Hospital Charge Code |
1711892
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.04
|
| Rate for Payer: Blue Distinction Transplant |
$13.13
|
| Rate for Payer: Blue Shield of California Commercial |
$16.13
|
| Rate for Payer: Blue Shield of California EPN |
$12.78
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: Dignity Health Media |
$18.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$16.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0277-31
|
| Hospital Charge Code |
1711892
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Blue Shield of California Commercial |
$15.59
|
| Rate for Payer: Blue Shield of California EPN |
$11.21
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0277-01
|
| Hospital Charge Code |
1711892
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Blue Shield of California Commercial |
$15.59
|
| Rate for Payer: Blue Shield of California EPN |
$11.21
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0277-31
|
| Hospital Charge Code |
1711892
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.04
|
| Rate for Payer: Blue Distinction Transplant |
$13.13
|
| Rate for Payer: Blue Shield of California Commercial |
$16.13
|
| Rate for Payer: Blue Shield of California EPN |
$12.78
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: Dignity Health Media |
$18.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$16.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
|
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0221-31
|
| Hospital Charge Code |
1711890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Blue Shield of California Commercial |
$15.59
|
| Rate for Payer: Blue Shield of California EPN |
$11.21
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
|
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0221-31
|
| Hospital Charge Code |
1711890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.04
|
| Rate for Payer: Blue Distinction Transplant |
$13.13
|
| Rate for Payer: Blue Shield of California Commercial |
$16.13
|
| Rate for Payer: Blue Shield of California EPN |
$12.78
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: Dignity Health Media |
$18.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$16.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0112-31
|
| Hospital Charge Code |
1711891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Blue Shield of California Commercial |
$15.59
|
| Rate for Payer: Blue Shield of California EPN |
$11.21
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0112-28
|
| Hospital Charge Code |
1711891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Blue Shield of California Commercial |
$15.59
|
| Rate for Payer: Blue Shield of California EPN |
$11.21
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0112-31
|
| Hospital Charge Code |
1711891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.04
|
| Rate for Payer: Blue Distinction Transplant |
$13.13
|
| Rate for Payer: Blue Shield of California Commercial |
$16.13
|
| Rate for Payer: Blue Shield of California EPN |
$12.78
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: Dignity Health Media |
$18.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$16.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0112-28
|
| Hospital Charge Code |
1711891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.04
|
| Rate for Payer: Blue Distinction Transplant |
$13.13
|
| Rate for Payer: Blue Shield of California Commercial |
$16.13
|
| Rate for Payer: Blue Shield of California EPN |
$12.78
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: Dignity Health Media |
$18.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$16.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
|
IP
|
$48,046.57
|
|
|
Service Code
|
APR-DRG 3123
|
| Min. Negotiated Rate |
$36,856.78 |
| Max. Negotiated Rate |
$48,046.57 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$36,856.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48,046.57
|
|
|
SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
|
IP
|
$28,444.52
|
|
|
Service Code
|
APR-DRG 3122
|
| Min. Negotiated Rate |
$21,819.94 |
| Max. Negotiated Rate |
$28,444.52 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21,819.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28,444.52
|
|
|
SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
|
IP
|
$17,755.88
|
|
|
Service Code
|
APR-DRG 3121
|
| Min. Negotiated Rate |
$13,620.63 |
| Max. Negotiated Rate |
$17,755.88 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,620.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,755.88
|
|
|
SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
|
IP
|
$97,440.99
|
|
|
Service Code
|
APR-DRG 3124
|
| Min. Negotiated Rate |
$74,747.49 |
| Max. Negotiated Rate |
$97,440.99 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$74,747.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97,440.99
|
|
|
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES
|
Facility
|
IP
|
$41,039.64
|
|
|
Service Code
|
APR-DRG 3613
|
| Min. Negotiated Rate |
$31,481.72 |
| Max. Negotiated Rate |
$41,039.64 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$31,481.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41,039.64
|
|
|
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES
|
Facility
|
IP
|
$82,519.09
|
|
|
Service Code
|
APR-DRG 3614
|
| Min. Negotiated Rate |
$63,300.83 |
| Max. Negotiated Rate |
$82,519.09 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$63,300.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$82,519.09
|
|
