|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
IP
|
$23.00
|
|
|
Service Code
|
NDC 45802-580-01
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.52 |
| Max. Negotiated Rate |
$19.55 |
| Rate for Payer: Blue Shield of California Commercial |
$16.38
|
| Rate for Payer: Blue Shield of California EPN |
$11.78
|
| Rate for Payer: Cash Price |
$10.35
|
| Rate for Payer: Cigna of CA HMO |
$16.10
|
| Rate for Payer: Cigna of CA PPO |
$16.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.20
|
| Rate for Payer: Galaxy Health WC |
$19.55
|
| Rate for Payer: Global Benefits Group Commercial |
$13.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Networks By Design Commercial |
$14.95
|
| Rate for Payer: Prime Health Services Commercial |
$19.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
OP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-97
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.14
|
| Rate for Payer: BCBS Transplant Transplant |
$13.24
|
| Rate for Payer: Blue Shield of California Commercial |
$16.26
|
| Rate for Payer: Blue Shield of California EPN |
$12.88
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cigna of CA HMO |
$15.44
|
| Rate for Payer: Cigna of CA PPO |
$15.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.75
|
| Rate for Payer: Dignity Health Media |
$18.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.82
|
| Rate for Payer: Galaxy Health WC |
$18.75
|
| Rate for Payer: Global Benefits Group Commercial |
$13.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$16.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.29
|
| Rate for Payer: Multiplan Commercial |
$17.65
|
| Rate for Payer: Networks By Design Commercial |
$14.34
|
| Rate for Payer: Prime Health Services Commercial |
$18.75
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.03
|
| Rate for Payer: United Healthcare All Other HMO |
$11.03
|
| Rate for Payer: United Healthcare HMO Rider |
$11.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.75
|
| Rate for Payer: Vantage Medical Group Senior |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
IP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-97
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Blue Shield of California Commercial |
$15.71
|
| Rate for Payer: Blue Shield of California EPN |
$11.29
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cigna of CA HMO |
$15.44
|
| Rate for Payer: Cigna of CA PPO |
$15.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.82
|
| Rate for Payer: Galaxy Health WC |
$18.75
|
| Rate for Payer: Global Benefits Group Commercial |
$13.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.29
|
| Rate for Payer: Multiplan Commercial |
$17.65
|
| Rate for Payer: Networks By Design Commercial |
$14.34
|
| Rate for Payer: Prime Health Services Commercial |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
OP
|
$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: Aetna of CA HMO/PPO |
$12.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.55
|
| Rate for Payer: BCBS Transplant Transplant |
$11.63
|
| Rate for Payer: Blue Shield of California Commercial |
$14.29
|
| Rate for Payer: Blue Shield of California EPN |
$11.32
|
| 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: Dignity Health Commercial/Exchange |
$16.48
|
| Rate for Payer: Dignity Health Media |
$16.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.76
|
| Rate for Payer: Galaxy Health WC |
$16.48
|
| Rate for Payer: Global Benefits Group Commercial |
$11.63
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$14.54
|
| 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: Networks By Design Commercial |
$12.60
|
| Rate for Payer: Prime Health Services Commercial |
$16.48
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$11.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.70
|
| Rate for Payer: United Healthcare All Other HMO |
$9.70
|
| Rate for Payer: United Healthcare HMO Rider |
$9.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.48
|
| Rate for Payer: Vantage Medical Group Senior |
$16.48
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
OP
|
$19.26
|
|
|
Service Code
|
NDC 45802-580-84
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$16.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12.63
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.48
|
| Rate for Payer: BCBS Transplant Transplant |
$11.56
|
| Rate for Payer: Blue Shield of California Commercial |
$14.19
|
| Rate for Payer: Blue Shield of California EPN |
$11.25
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cigna of CA HMO |
$13.48
|
| Rate for Payer: Cigna of CA PPO |
$13.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.37
|
| Rate for Payer: Dignity Health Media |
$16.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.70
|
| Rate for Payer: Galaxy Health WC |
$16.37
|
| Rate for Payer: Global Benefits Group Commercial |
$11.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$14.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: Multiplan Commercial |
$15.41
|
| Rate for Payer: Networks By Design Commercial |
$12.52
|
| Rate for Payer: Prime Health Services Commercial |
$16.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$11.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.63
|
| Rate for Payer: United Healthcare All Other HMO |
$9.63
|
| Rate for Payer: United Healthcare HMO Rider |
$9.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.37
|
| Rate for Payer: Vantage Medical Group Senior |
$16.37
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
IP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-16
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Blue Shield of California Commercial |
$15.71
|
| Rate for Payer: Blue Shield of California EPN |
$11.29
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cigna of CA HMO |
$15.44
|
| Rate for Payer: Cigna of CA PPO |
$15.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.82
|
| Rate for Payer: Galaxy Health WC |
$18.75
|
| Rate for Payer: Global Benefits Group Commercial |
$13.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.29
|
| Rate for Payer: Multiplan Commercial |
$17.65
|
| Rate for Payer: Networks By Design Commercial |
$14.34
|
| Rate for Payer: Prime Health Services Commercial |
$18.75
|
|
|
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
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
OP
|
$23.00
|
|
|
Service Code
|
NDC 45802-580-01
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.52 |
| Max. Negotiated Rate |
$19.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$15.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.70
|
| Rate for Payer: BCBS Transplant Transplant |
$13.80
|
| Rate for Payer: Blue Shield of California Commercial |
$16.95
|
| Rate for Payer: Blue Shield of California EPN |
$13.43
|
| Rate for Payer: Cash Price |
$10.35
|
| Rate for Payer: Cigna of CA HMO |
$16.10
|
| Rate for Payer: Cigna of CA PPO |
$16.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.55
|
| Rate for Payer: Dignity Health Media |
$19.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.20
|
| Rate for Payer: Galaxy Health WC |
$19.55
|
| Rate for Payer: Global Benefits Group Commercial |
$13.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$17.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Networks By Design Commercial |
$14.95
|
| Rate for Payer: Prime Health Services Commercial |
$19.55
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.50
|
| Rate for Payer: United Healthcare All Other HMO |
$11.50
|
| Rate for Payer: United Healthcare HMO Rider |
$11.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.55
|
| Rate for Payer: Vantage Medical Group Senior |
$19.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
IP
|
$19.26
|
|
|
Service Code
|
NDC 45802-580-84
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$16.37 |
| Rate for Payer: Blue Shield of California Commercial |
$13.71
|
| Rate for Payer: Blue Shield of California EPN |
$9.86
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cigna of CA HMO |
$13.48
|
| Rate for Payer: Cigna of CA PPO |
$13.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.70
|
| Rate for Payer: Galaxy Health WC |
$16.37
|
| Rate for Payer: Global Benefits Group Commercial |
$11.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: Multiplan Commercial |
$15.41
|
| Rate for Payer: Networks By Design Commercial |
$12.52
|
| Rate for Payer: Prime Health Services Commercial |
$16.37
|
|
|
SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]
|
Facility
IP
|
$630.00
|
|
|
Service Code
|
CPT J2850
|
| Hospital Charge Code |
ERX91185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$151.20 |
| Max. Negotiated Rate |
$535.50 |
| Rate for Payer: Blue Shield of California Commercial |
$448.56
|
| Rate for Payer: Blue Shield of California EPN |
$322.56
|
| Rate for Payer: Cash Price |
$283.50
|
| Rate for Payer: Cigna of CA HMO |
$441.00
|
| Rate for Payer: Cigna of CA PPO |
$441.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$252.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$252.00
|
| Rate for Payer: Galaxy Health WC |
$535.50
|
| Rate for Payer: Global Benefits Group Commercial |
$378.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$420.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$240.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.20
|
| Rate for Payer: Multiplan Commercial |
$504.00
|
| Rate for Payer: Networks By Design Commercial |
$315.00
|
| Rate for Payer: Prime Health Services Commercial |
$535.50
|
|
|
SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]
|
Facility
OP
|
$630.00
|
|
|
Service Code
|
CPT J2850
|
| Hospital Charge Code |
ERX91185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.38 |
| Max. Negotiated Rate |
$535.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$203.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$52.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$45.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$45.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$45.18
|
| Rate for Payer: BCBS Transplant Transplant |
$378.00
|
| Rate for Payer: Blue Shield of California Commercial |
$464.31
|
| Rate for Payer: Blue Shield of California EPN |
$39.38
|
| Rate for Payer: Cash Price |
$283.50
|
| Rate for Payer: Cash Price |
$283.50
|
| Rate for Payer: Cigna of CA HMO |
$441.00
|
| Rate for Payer: Cigna of CA PPO |
$441.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62.61
|
| Rate for Payer: Dignity Health Media |
$41.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.35
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$41.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.74
|
| Rate for Payer: Galaxy Health WC |
$535.50
|
| Rate for Payer: Global Benefits Group Commercial |
$378.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$472.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$68.45
|
| Rate for Payer: Heritage Provider Network Transplant |
$68.45
|
| Rate for Payer: IEHP Medi-Cal |
$67.62
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$67.62
|
| Rate for Payer: IEHP Medicare Advantage |
$41.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$420.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$70.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$41.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$52.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$55.93
|
| Rate for Payer: Multiplan Commercial |
$504.00
|
| Rate for Payer: Networks By Design Commercial |
$315.00
|
| Rate for Payer: Prime Health Services Commercial |
$535.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$378.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$378.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$315.00
|
| Rate for Payer: United Healthcare All Other HMO |
$315.00
|
| Rate for Payer: United Healthcare HMO Rider |
$315.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$315.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$62.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.91
|
| Rate for Payer: Vantage Medical Group Senior |
$41.74
|
|
|
SEIZURE
|
Facility
IP
|
$12,678.47
|
|
|
Service Code
|
APR-DRG 0533
|
| Min. Negotiated Rate |
$9,725.72 |
| Max. Negotiated Rate |
$12,678.47 |
| Rate for Payer: IEHP Medi-Cal |
$9,725.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,678.47
|
|
|
SEIZURE
|
Facility
IP
|
$7,629.43
|
|
|
Service Code
|
APR-DRG 0531
|
| Min. Negotiated Rate |
$5,852.58 |
| Max. Negotiated Rate |
$7,629.43 |
| Rate for Payer: IEHP Medi-Cal |
$5,852.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7,629.43
|
|
|
SEIZURE
|
Facility
IP
|
$28,848.88
|
|
|
Service Code
|
APR-DRG 0534
|
| Min. Negotiated Rate |
$22,130.13 |
| Max. Negotiated Rate |
$28,848.88 |
| Rate for Payer: IEHP Medi-Cal |
$22,130.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28,848.88
|
|
|
SEIZURE
|
Facility
IP
|
$9,730.98
|
|
|
Service Code
|
APR-DRG 0532
|
| Min. Negotiated Rate |
$7,464.69 |
| Max. Negotiated Rate |
$9,730.98 |
| Rate for Payer: IEHP Medi-Cal |
$7,464.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,730.98
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
OP
|
$2.01
|
|
|
Service Code
|
NDC 60505-0055-1
|
| Hospital Charge Code |
1712623
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.20
|
| Rate for Payer: BCBS Transplant Transplant |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO |
$1.41
|
| Rate for Payer: Cigna of CA PPO |
$1.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.71
|
| Rate for Payer: Dignity Health Media |
$1.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.71
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.61
|
| Rate for Payer: Networks By Design Commercial |
$1.31
|
| Rate for Payer: Prime Health Services Commercial |
$1.71
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1.71
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
IP
|
$2.01
|
|
|
Service Code
|
NDC 60505-0055-1
|
| Hospital Charge Code |
1712623
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Blue Shield of California Commercial |
$1.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO |
$1.41
|
| Rate for Payer: Cigna of CA PPO |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.71
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.61
|
| Rate for Payer: Networks By Design Commercial |
$1.31
|
| Rate for Payer: Prime Health Services Commercial |
$1.71
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
OP
|
$0.06
|
|
|
Service Code
|
NDC 7985401163
|
| Hospital Charge Code |
ERX7139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: BCBS Transplant Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Media |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
IP
|
$0.06
|
|
|
Service Code
|
NDC 7985401163
|
| Hospital Charge Code |
ERX7139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
SELENIUM 50 MCG TABLET [7140]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 26899-721-74
|
| Hospital Charge Code |
1710887
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: BCBS Transplant Transplant |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Media |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
SELENIUM 50 MCG TABLET [7140]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 26899-721-74
|
| Hospital Charge Code |
1710887
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]
|
Facility
OP
|
$41.16
|
|
|
Service Code
|
NDC 0517-6560-25
|
| Hospital Charge Code |
NDG225026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.88 |
| Max. Negotiated Rate |
$34.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$34.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$22.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$22.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.52
|
| Rate for Payer: BCBS Transplant Transplant |
$24.70
|
| Rate for Payer: Blue Shield of California Commercial |
$30.33
|
| Rate for Payer: Blue Shield of California EPN |
$24.04
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: Cigna of CA HMO |
$26.34
|
| Rate for Payer: Cigna of CA PPO |
$30.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$34.99
|
| Rate for Payer: Dignity Health Media |
$34.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$16.46
|
| Rate for Payer: Galaxy Health WC |
$34.99
|
| Rate for Payer: Global Benefits Group Commercial |
$24.70
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$30.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$27.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.88
|
| Rate for Payer: Multiplan Commercial |
$32.93
|
| Rate for Payer: Networks By Design Commercial |
$26.75
|
| Rate for Payer: Prime Health Services Commercial |
$34.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$24.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$24.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$20.58
|
| Rate for Payer: United Healthcare All Other HMO |
$20.58
|
| Rate for Payer: United Healthcare HMO Rider |
$20.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$20.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$34.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.99
|
| Rate for Payer: Vantage Medical Group Senior |
$34.99
|
|
|
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]
|
Facility
IP
|
$41.16
|
|
|
Service Code
|
NDC 0517-6560-25
|
| Hospital Charge Code |
NDG225026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.88 |
| Max. Negotiated Rate |
$34.99 |
| Rate for Payer: Blue Shield of California Commercial |
$29.31
|
| Rate for Payer: Blue Shield of California EPN |
$21.07
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.46
|
| Rate for Payer: Galaxy Health WC |
$34.99
|
| Rate for Payer: Global Benefits Group Commercial |
$24.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$27.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.88
|
| Rate for Payer: Multiplan Commercial |
$32.93
|
| Rate for Payer: Networks By Design Commercial |
$26.75
|
| Rate for Payer: Prime Health Services Commercial |
$34.99
|
|
|
SELENIUM SULFIDE 1 % SHAMPOO [38961]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 0536-1995-53
|
| Hospital Charge Code |
1743730
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
SELENIUM SULFIDE 1 % SHAMPOO [38961]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 0536-1995-53
|
| Hospital Charge Code |
1743730
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: BCBS Transplant Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Media |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
