|
SEVELAMER HCL 800 MG TABLET [28715]
|
Facility
OP
|
$8.92
|
|
|
Service Code
|
NDC 58468-0021-1
|
| Hospital Charge Code |
1712253
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$7.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.31
|
| Rate for Payer: BCBS Transplant Transplant |
$5.35
|
| Rate for Payer: Blue Shield of California Commercial |
$6.57
|
| Rate for Payer: Blue Shield of California EPN |
$5.21
|
| Rate for Payer: Cash Price |
$4.01
|
| Rate for Payer: Cigna of CA HMO |
$6.24
|
| Rate for Payer: Cigna of CA PPO |
$6.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.58
|
| Rate for Payer: Dignity Health Media |
$7.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.57
|
| Rate for Payer: Galaxy Health WC |
$7.58
|
| Rate for Payer: Global Benefits Group Commercial |
$5.35
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$7.14
|
| Rate for Payer: Networks By Design Commercial |
$5.80
|
| Rate for Payer: Prime Health Services Commercial |
$7.58
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Other HMO |
$4.46
|
| Rate for Payer: United Healthcare HMO Rider |
$4.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.58
|
| Rate for Payer: Vantage Medical Group Senior |
$7.58
|
|
|
SEVELAMER ORAL SUSPENSION COMPOUND 50 MG/ML [4080333]
|
Facility
OP
|
$0.47
|
|
|
Service Code
|
NDC 9994-0803-33
|
| Hospital Charge Code |
1715236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: BCBS Transplant Transplant |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Media |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
SEVELAMER ORAL SUSPENSION COMPOUND 50 MG/ML [4080333]
|
Facility
IP
|
$0.47
|
|
|
Service Code
|
NDC 9994-0803-33
|
| Hospital Charge Code |
1715236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
|
|
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm
|
Facility
OP
|
$4,984.00
|
|
|
Service Code
|
CPT 11301
|
| Min. Negotiated Rate |
$217.34 |
| Max. Negotiated Rate |
$4,984.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$295.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,984.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Media |
$250.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$337.69
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$250.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$410.23
|
| Rate for Payer: Heritage Provider Network Transplant |
$410.23
|
| Rate for Payer: IEHP Medi-Cal |
$405.23
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$405.23
|
| Rate for Payer: IEHP Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$250.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$335.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
SHOULDER AND ELBOW JOINT REPLACEMENT
|
Facility
IP
|
$54,560.50
|
|
|
Service Code
|
APR-DRG 3224
|
| Min. Negotiated Rate |
$41,853.64 |
| Max. Negotiated Rate |
$54,560.50 |
| Rate for Payer: IEHP Medi-Cal |
$41,853.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54,560.50
|
|
|
SHOULDER AND ELBOW JOINT REPLACEMENT
|
Facility
IP
|
$28,579.31
|
|
|
Service Code
|
APR-DRG 3221
|
| Min. Negotiated Rate |
$21,923.34 |
| Max. Negotiated Rate |
$28,579.31 |
| Rate for Payer: IEHP Medi-Cal |
$21,923.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28,579.31
|
|
|
SHOULDER AND ELBOW JOINT REPLACEMENT
|
Facility
IP
|
$31,030.23
|
|
|
Service Code
|
APR-DRG 3222
|
| Min. Negotiated Rate |
$23,803.45 |
| Max. Negotiated Rate |
$31,030.23 |
| Rate for Payer: IEHP Medi-Cal |
$23,803.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31,030.23
|
|
|
SHOULDER AND ELBOW JOINT REPLACEMENT
|
Facility
IP
|
$40,748.79
|
|
|
Service Code
|
APR-DRG 3223
|
| Min. Negotiated Rate |
$31,258.61 |
| Max. Negotiated Rate |
$40,748.79 |
| Rate for Payer: IEHP Medi-Cal |
$31,258.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40,748.79
|
|
|
SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT
|
Facility
IP
|
$36,102.32
|
|
|
Service Code
|
APR-DRG 3153
|
| Min. Negotiated Rate |
$27,694.28 |
| Max. Negotiated Rate |
$36,102.32 |
| Rate for Payer: IEHP Medi-Cal |
$27,694.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36,102.32
|
|
|
SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT
|
Facility
IP
|
$58,703.29
|
|
|
Service Code
|
APR-DRG 3154
|
| Min. Negotiated Rate |
$45,031.61 |
| Max. Negotiated Rate |
$58,703.29 |
| Rate for Payer: IEHP Medi-Cal |
$45,031.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$58,703.29
|
|
|
SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT
|
Facility
IP
|
$15,140.04
|
|
|
Service Code
|
APR-DRG 3151
|
| Min. Negotiated Rate |
$11,614.00 |
| Max. Negotiated Rate |
$15,140.04 |
| Rate for Payer: IEHP Medi-Cal |
$11,614.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15,140.04
|
|
|
SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT
|
Facility
IP
|
$24,229.01
|
|
|
Service Code
|
APR-DRG 3152
|
| Min. Negotiated Rate |
$18,586.20 |
| Max. Negotiated Rate |
$24,229.01 |
| Rate for Payer: IEHP Medi-Cal |
$18,586.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,229.01
|
|
|
SICKLE CELL ANEMIA CRISIS
|
Facility
IP
|
$10,752.48
|
|
|
Service Code
|
APR-DRG 6622
|
| Min. Negotiated Rate |
$8,248.28 |
| Max. Negotiated Rate |
$10,752.48 |
| Rate for Payer: IEHP Medi-Cal |
$8,248.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,752.48
|
|
|
SICKLE CELL ANEMIA CRISIS
|
Facility
IP
|
$28,662.66
|
|
|
Service Code
|
APR-DRG 6624
|
| Min. Negotiated Rate |
$21,987.28 |
| Max. Negotiated Rate |
$28,662.66 |
| Rate for Payer: IEHP Medi-Cal |
$21,987.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28,662.66
|
|
|
SICKLE CELL ANEMIA CRISIS
|
Facility
IP
|
$15,244.67
|
|
|
Service Code
|
APR-DRG 6623
|
| Min. Negotiated Rate |
$11,694.27 |
| Max. Negotiated Rate |
$15,244.67 |
| Rate for Payer: IEHP Medi-Cal |
$11,694.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15,244.67
|
|
|
SICKLE CELL ANEMIA CRISIS
|
Facility
IP
|
$7,840.46
|
|
|
Service Code
|
APR-DRG 6621
|
| Min. Negotiated Rate |
$6,014.46 |
| Max. Negotiated Rate |
$7,840.46 |
| Rate for Payer: IEHP Medi-Cal |
$6,014.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7,840.46
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
IP
|
$9,459.64
|
|
|
Service Code
|
APR-DRG 8612
|
| Min. Negotiated Rate |
$7,256.54 |
| Max. Negotiated Rate |
$9,459.64 |
| Rate for Payer: IEHP Medi-Cal |
$7,256.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,459.64
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
IP
|
$14,294.08
|
|
|
Service Code
|
APR-DRG 8614
|
| Min. Negotiated Rate |
$10,965.06 |
| Max. Negotiated Rate |
$14,294.08 |
| Rate for Payer: IEHP Medi-Cal |
$10,965.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14,294.08
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
IP
|
$5,458.72
|
|
|
Service Code
|
APR-DRG 8611
|
| Min. Negotiated Rate |
$4,187.41 |
| Max. Negotiated Rate |
$5,458.72 |
| Rate for Payer: IEHP Medi-Cal |
$4,187.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,458.72
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
IP
|
$13,233.56
|
|
|
Service Code
|
APR-DRG 8613
|
| Min. Negotiated Rate |
$10,151.53 |
| Max. Negotiated Rate |
$13,233.56 |
| Rate for Payer: IEHP Medi-Cal |
$10,151.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,233.56
|
|
|
SILDENAFIL 25 MG TABLET [22836]
|
Facility
OP
|
$99.92
|
|
|
Service Code
|
NDC 0069-4200-30
|
| Hospital Charge Code |
1710917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.98 |
| Max. Negotiated Rate |
$84.93 |
| Rate for Payer: Aetna of CA HMO/PPO |
$65.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$84.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$54.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$54.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.53
|
| Rate for Payer: BCBS Transplant Transplant |
$59.95
|
| Rate for Payer: Blue Shield of California Commercial |
$73.64
|
| Rate for Payer: Blue Shield of California EPN |
$58.35
|
| Rate for Payer: Cash Price |
$44.96
|
| Rate for Payer: Cigna of CA HMO |
$69.94
|
| Rate for Payer: Cigna of CA PPO |
$69.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$84.93
|
| Rate for Payer: Dignity Health Media |
$84.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$84.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.97
|
| Rate for Payer: EPIC Health Plan Transplant |
$39.97
|
| Rate for Payer: Galaxy Health WC |
$84.93
|
| Rate for Payer: Global Benefits Group Commercial |
$59.95
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$74.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$66.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.98
|
| Rate for Payer: Multiplan Commercial |
$79.94
|
| Rate for Payer: Networks By Design Commercial |
$64.95
|
| Rate for Payer: Prime Health Services Commercial |
$84.93
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$59.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$59.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$59.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$49.96
|
| Rate for Payer: United Healthcare All Other HMO |
$49.96
|
| Rate for Payer: United Healthcare HMO Rider |
$49.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$49.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$84.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$84.93
|
| Rate for Payer: Vantage Medical Group Senior |
$84.93
|
|
|
SILDENAFIL 25 MG TABLET [22836]
|
Facility
IP
|
$99.92
|
|
|
Service Code
|
NDC 0069-4200-30
|
| Hospital Charge Code |
1710917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.98 |
| Max. Negotiated Rate |
$84.93 |
| Rate for Payer: Blue Shield of California Commercial |
$71.14
|
| Rate for Payer: Blue Shield of California EPN |
$51.16
|
| Rate for Payer: Cash Price |
$44.96
|
| Rate for Payer: Cigna of CA HMO |
$69.94
|
| Rate for Payer: Cigna of CA PPO |
$69.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.97
|
| Rate for Payer: Galaxy Health WC |
$84.93
|
| Rate for Payer: Global Benefits Group Commercial |
$59.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$66.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.98
|
| Rate for Payer: Multiplan Commercial |
$79.94
|
| Rate for Payer: Networks By Design Commercial |
$64.95
|
| Rate for Payer: Prime Health Services Commercial |
$84.93
|
|
|
SILDENAFIL ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080335]
|
Facility
OP
|
$2.81
|
|
|
Service Code
|
NDC 9994-0803-35
|
| Hospital Charge Code |
1715001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.67
|
| Rate for Payer: BCBS Transplant Transplant |
$1.69
|
| Rate for Payer: Blue Shield of California Commercial |
$2.07
|
| Rate for Payer: Blue Shield of California EPN |
$1.64
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cigna of CA HMO |
$1.97
|
| Rate for Payer: Cigna of CA PPO |
$1.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.39
|
| Rate for Payer: Dignity Health Media |
$2.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.39
|
| Rate for Payer: Global Benefits Group Commercial |
$1.69
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: Networks By Design Commercial |
$1.83
|
| Rate for Payer: Prime Health Services Commercial |
$2.39
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.69
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.40
|
| Rate for Payer: United Healthcare All Other HMO |
$1.40
|
| Rate for Payer: United Healthcare HMO Rider |
$1.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.39
|
| Rate for Payer: Vantage Medical Group Senior |
$2.39
|
|
|
SILDENAFIL ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080335]
|
Facility
IP
|
$2.81
|
|
|
Service Code
|
NDC 9994-0803-35
|
| Hospital Charge Code |
1715001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Blue Shield of California Commercial |
$2.00
|
| Rate for Payer: Blue Shield of California EPN |
$1.44
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cigna of CA HMO |
$1.97
|
| Rate for Payer: Cigna of CA PPO |
$1.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.39
|
| Rate for Payer: Global Benefits Group Commercial |
$1.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: Networks By Design Commercial |
$1.83
|
| Rate for Payer: Prime Health Services Commercial |
$2.39
|
|
|
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]
|
Facility
IP
|
$0.89
|
|
|
Service Code
|
CPT S0090
|
| Hospital Charge Code |
1711956
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Galaxy Health WC |
$0.76
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Prime Health Services Commercial |
$0.76
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
|
