|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
IP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0777-20
|
| Hospital Charge Code |
ERX210398
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Blue Shield of California Commercial |
$9.51
|
| Rate for Payer: Blue Shield of California EPN |
$6.84
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: Cigna of CA HMO |
$9.35
|
| Rate for Payer: Cigna of CA PPO |
$9.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.34
|
| Rate for Payer: Galaxy Health WC |
$11.36
|
| Rate for Payer: Global Benefits Group Commercial |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$10.69
|
| Rate for Payer: Networks By Design Commercial |
$8.68
|
| Rate for Payer: Prime Health Services Commercial |
$11.36
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
IP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0696-20
|
| Hospital Charge Code |
ERX210399
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Blue Shield of California Commercial |
$9.51
|
| Rate for Payer: Blue Shield of California EPN |
$6.84
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: Cigna of CA HMO |
$9.35
|
| Rate for Payer: Cigna of CA PPO |
$9.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.34
|
| Rate for Payer: Galaxy Health WC |
$11.36
|
| Rate for Payer: Global Benefits Group Commercial |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$10.69
|
| Rate for Payer: Networks By Design Commercial |
$8.68
|
| Rate for Payer: Prime Health Services Commercial |
$11.36
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
OP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0696-20
|
| Hospital Charge Code |
ERX210399
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$8.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.96
|
| Rate for Payer: BCBS Transplant Transplant |
$8.02
|
| Rate for Payer: Blue Shield of California Commercial |
$9.85
|
| Rate for Payer: Blue Shield of California EPN |
$7.80
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: Cigna of CA HMO |
$9.35
|
| Rate for Payer: Cigna of CA PPO |
$9.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.36
|
| Rate for Payer: Dignity Health Media |
$11.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.34
|
| Rate for Payer: Galaxy Health WC |
$11.36
|
| Rate for Payer: Global Benefits Group Commercial |
$8.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$10.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$10.69
|
| Rate for Payer: Networks By Design Commercial |
$8.68
|
| Rate for Payer: Prime Health Services Commercial |
$11.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$8.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.68
|
| Rate for Payer: United Healthcare All Other HMO |
$6.68
|
| Rate for Payer: United Healthcare HMO Rider |
$6.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.36
|
| Rate for Payer: Vantage Medical Group Senior |
$11.36
|
|
|
SALICYLIC ACID 17 % TOPICAL LIQUID [11323]
|
Facility
IP
|
$0.62
|
|
|
Service Code
|
NDC 1101725220
|
| Hospital Charge Code |
NDG11323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
|
|
SALICYLIC ACID 17 % TOPICAL LIQUID [11323]
|
Facility
OP
|
$0.62
|
|
|
Service Code
|
NDC 1101725220
|
| Hospital Charge Code |
NDG11323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: BCBS Transplant Transplant |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Media |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
NDC 4858251201
|
| Hospital Charge Code |
NDG216603
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]
|
Facility
OP
|
$0.14
|
|
|
Service Code
|
NDC 4858251201
|
| Hospital Charge Code |
NDG216603
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: BCBS Transplant Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
OP
|
$0.33
|
|
|
Service Code
|
NDC 73090-0800-02
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: BCBS Transplant Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Media |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 8489800001
|
| Hospital Charge Code |
1719220
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: BCBS Transplant Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Media |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 8489800001
|
| Hospital Charge Code |
1719220
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 6014629157
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: BCBS Transplant Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Media |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 6014629157
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
IP
|
$0.33
|
|
|
Service Code
|
NDC 73090-0800-02
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
|
|
SAQUINAVIR 500 MG TABLET [40401]
|
Facility
OP
|
$12.02
|
|
|
Service Code
|
NDC 0004-0244-51
|
| Hospital Charge Code |
1710991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$10.22 |
| Rate for Payer: BCBS Transplant Transplant |
$7.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.61
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.16
|
| Rate for Payer: Blue Shield of California Commercial |
$8.86
|
| Rate for Payer: Blue Shield of California EPN |
$7.02
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: Cigna of CA HMO |
$8.41
|
| Rate for Payer: Cigna of CA PPO |
$8.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.22
|
| Rate for Payer: Dignity Health Media |
$10.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.81
|
| Rate for Payer: Galaxy Health WC |
$10.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.21
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$9.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$9.62
|
| Rate for Payer: Networks By Design Commercial |
$7.81
|
| Rate for Payer: Prime Health Services Commercial |
$10.22
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$7.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.01
|
| Rate for Payer: United Healthcare All Other HMO |
$6.01
|
| Rate for Payer: United Healthcare HMO Rider |
$6.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.22
|
| Rate for Payer: Vantage Medical Group Senior |
$10.22
|
|
|
SAQUINAVIR 500 MG TABLET [40401]
|
Facility
IP
|
$12.02
|
|
|
Service Code
|
NDC 0004-0244-51
|
| Hospital Charge Code |
1710991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$10.22 |
| Rate for Payer: Blue Shield of California Commercial |
$8.56
|
| Rate for Payer: Blue Shield of California EPN |
$6.15
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: Cigna of CA HMO |
$8.41
|
| Rate for Payer: Cigna of CA PPO |
$8.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.81
|
| Rate for Payer: Galaxy Health WC |
$10.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$9.62
|
| Rate for Payer: Networks By Design Commercial |
$7.81
|
| Rate for Payer: Prime Health Services Commercial |
$10.22
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS PEN INJECTOR [221911]
|
Facility
OP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG221911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$517.55 |
| Max. Negotiated Rate |
$1,832.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,414.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,832.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,186.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,186.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,284.82
|
| Rate for Payer: BCBS Transplant Transplant |
$1,293.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1,589.31
|
| Rate for Payer: Blue Shield of California EPN |
$1,259.37
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cigna of CA HMO |
$1,509.52
|
| Rate for Payer: Cigna of CA PPO |
$1,509.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,832.99
|
| Rate for Payer: Dignity Health Media |
$1,832.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,832.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$862.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$862.58
|
| Rate for Payer: Galaxy Health WC |
$1,832.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1,293.88
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,617.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,438.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$821.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$517.55
|
| Rate for Payer: Multiplan Commercial |
$1,725.17
|
| Rate for Payer: Networks By Design Commercial |
$1,078.23
|
| Rate for Payer: Prime Health Services Commercial |
$1,832.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,293.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,293.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,078.23
|
| Rate for Payer: United Healthcare All Other HMO |
$1,078.23
|
| Rate for Payer: United Healthcare HMO Rider |
$1,078.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,078.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,832.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,832.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1,832.99
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS PEN INJECTOR [221911]
|
Facility
IP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG221911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$517.55 |
| Max. Negotiated Rate |
$1,832.99 |
| Rate for Payer: Blue Shield of California Commercial |
$1,535.40
|
| Rate for Payer: Blue Shield of California EPN |
$1,104.11
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cigna of CA HMO |
$1,509.52
|
| Rate for Payer: Cigna of CA PPO |
$1,509.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$862.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$862.58
|
| Rate for Payer: Galaxy Health WC |
$1,832.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1,293.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,438.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$821.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$517.55
|
| Rate for Payer: Multiplan Commercial |
$1,725.17
|
| Rate for Payer: Networks By Design Commercial |
$1,078.23
|
| Rate for Payer: Prime Health Services Commercial |
$1,832.99
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE [216968]
|
Facility
IP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG216968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$517.55 |
| Max. Negotiated Rate |
$1,832.99 |
| Rate for Payer: Blue Shield of California Commercial |
$1,535.40
|
| Rate for Payer: Blue Shield of California EPN |
$1,104.11
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cigna of CA HMO |
$1,509.52
|
| Rate for Payer: Cigna of CA PPO |
$1,509.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$862.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$862.58
|
| Rate for Payer: Galaxy Health WC |
$1,832.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1,293.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,438.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$821.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$517.55
|
| Rate for Payer: Multiplan Commercial |
$1,725.17
|
| Rate for Payer: Networks By Design Commercial |
$1,078.23
|
| Rate for Payer: Prime Health Services Commercial |
$1,832.99
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE [216968]
|
Facility
OP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG216968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$517.55 |
| Max. Negotiated Rate |
$1,832.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,414.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,832.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,186.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,186.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,284.82
|
| Rate for Payer: BCBS Transplant Transplant |
$1,293.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1,589.31
|
| Rate for Payer: Blue Shield of California EPN |
$1,259.37
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cigna of CA HMO |
$1,509.52
|
| Rate for Payer: Cigna of CA PPO |
$1,509.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,832.99
|
| Rate for Payer: Dignity Health Media |
$1,832.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,832.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$862.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$862.58
|
| Rate for Payer: Galaxy Health WC |
$1,832.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1,293.88
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,617.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,438.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$821.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$517.55
|
| Rate for Payer: Multiplan Commercial |
$1,725.17
|
| Rate for Payer: Networks By Design Commercial |
$1,078.23
|
| Rate for Payer: Prime Health Services Commercial |
$1,832.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,293.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,293.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,078.23
|
| Rate for Payer: United Healthcare All Other HMO |
$1,078.23
|
| Rate for Payer: United Healthcare HMO Rider |
$1,078.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,078.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,832.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,832.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1,832.99
|
|
|
SCHIZOPHRENIA
|
Facility
IP
|
$17,333.80
|
|
|
Service Code
|
APR-DRG 7503
|
| Min. Negotiated Rate |
$13,296.85 |
| Max. Negotiated Rate |
$17,333.80 |
| Rate for Payer: IEHP Medi-Cal |
$13,296.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,333.80
|
|
|
SCHIZOPHRENIA
|
Facility
IP
|
$39,198.79
|
|
|
Service Code
|
APR-DRG 7504
|
| Min. Negotiated Rate |
$30,069.60 |
| Max. Negotiated Rate |
$39,198.79 |
| Rate for Payer: IEHP Medi-Cal |
$30,069.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39,198.79
|
|
|
SCHIZOPHRENIA
|
Facility
IP
|
$8,308.66
|
|
|
Service Code
|
APR-DRG 7501
|
| Min. Negotiated Rate |
$6,373.62 |
| Max. Negotiated Rate |
$8,308.66 |
| Rate for Payer: IEHP Medi-Cal |
$6,373.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,308.66
|
|
|
SCHIZOPHRENIA
|
Facility
IP
|
$10,355.23
|
|
|
Service Code
|
APR-DRG 7502
|
| Min. Negotiated Rate |
$7,943.55 |
| Max. Negotiated Rate |
$10,355.23 |
| Rate for Payer: IEHP Medi-Cal |
$7,943.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,355.23
|
|
|
Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluoroscopy) and radiological supervision and interpretation when performed
|
Facility
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 49185
|
| Min. Negotiated Rate |
$1,749.33 |
| Max. Negotiated Rate |
$7,385.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7,385.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,025.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,984.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Dignity Health Media |
$2,025.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,228.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,734.68
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,025.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,025.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,322.13
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,322.13
|
| Rate for Payer: IEHP Medi-Cal |
$3,281.62
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$3,281.62
|
| Rate for Payer: IEHP Medicare Advantage |
$2,025.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,749.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,025.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,552.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,714.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
IP
|
$19.39
|
|
|
Service Code
|
NDC 0378-6470-99
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$16.48 |
| Rate for Payer: Networks By Design Commercial |
$12.60
|
| Rate for Payer: Blue Shield of California Commercial |
$13.81
|
| Rate for Payer: Blue Shield of California EPN |
$9.93
|
| Rate for Payer: Cash Price |
$8.73
|
| Rate for Payer: Cigna of CA HMO |
$13.57
|
| Rate for Payer: Cigna of CA PPO |
$13.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.76
|
| Rate for Payer: Galaxy Health WC |
$16.48
|
| Rate for Payer: Global Benefits Group Commercial |
$11.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.65
|
| Rate for Payer: Multiplan Commercial |
$15.51
|
| Rate for Payer: Prime Health Services Commercial |
$16.48
|
|
