|
SIMETHICONE 80 MG CHEWABLE TABLET [7227]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 49348-188-10
|
| Hospital Charge Code |
1711183
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: BCBS Transplant Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$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 |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SIMPLE SYRUP [7242]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 3172293747
|
| Hospital Charge Code |
ERX7242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| 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 |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
SIMPLE SYRUP [7242]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 395266116
|
| Hospital Charge Code |
ERX7242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| 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 |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
SIMPLE SYRUP [7242]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 3172293747
|
| Hospital Charge Code |
ERX7242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: BCBS Transplant Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$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 |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SIMPLE SYRUP [7242]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 395266116
|
| Hospital Charge Code |
ERX7242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: BCBS Transplant Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$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 |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SIMVASTATIN 20 MG TABLET [11365]
|
Facility
IP
|
$0.29
|
|
|
Service Code
|
NDC 68084-512-01
|
| Hospital Charge Code |
1711607
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
|
|
SIMVASTATIN 20 MG TABLET [11365]
|
Facility
OP
|
$0.29
|
|
|
Service Code
|
NDC 68084-512-01
|
| Hospital Charge Code |
1711607
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: BCBS Transplant Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Media |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]
|
Facility
IP
|
$152.00
|
|
|
Service Code
|
CPT J2805
|
| Hospital Charge Code |
ERX11368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.48 |
| Max. Negotiated Rate |
$129.20 |
| Rate for Payer: Blue Shield of California Commercial |
$108.22
|
| Rate for Payer: Blue Shield of California EPN |
$77.82
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna of CA HMO |
$106.40
|
| Rate for Payer: Cigna of CA PPO |
$106.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$60.80
|
| Rate for Payer: Galaxy Health WC |
$129.20
|
| Rate for Payer: Global Benefits Group Commercial |
$91.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$101.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.48
|
| Rate for Payer: Multiplan Commercial |
$121.60
|
| Rate for Payer: Networks By Design Commercial |
$76.00
|
| Rate for Payer: Prime Health Services Commercial |
$129.20
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]
|
Facility
OP
|
$152.00
|
|
|
Service Code
|
CPT J2805
|
| Hospital Charge Code |
ERX11368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.48 |
| Max. Negotiated Rate |
$837.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$837.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$129.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$83.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$83.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$114.67
|
| Rate for Payer: BCBS Transplant Transplant |
$91.20
|
| Rate for Payer: Blue Shield of California Commercial |
$112.02
|
| Rate for Payer: Blue Shield of California EPN |
$121.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna of CA HMO |
$106.40
|
| Rate for Payer: Cigna of CA PPO |
$106.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$129.20
|
| Rate for Payer: Dignity Health Media |
$129.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$129.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$60.80
|
| Rate for Payer: Galaxy Health WC |
$129.20
|
| Rate for Payer: Global Benefits Group Commercial |
$91.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$114.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$101.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$261.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.48
|
| Rate for Payer: Multiplan Commercial |
$121.60
|
| Rate for Payer: Networks By Design Commercial |
$76.00
|
| Rate for Payer: Prime Health Services Commercial |
$129.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$91.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$91.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$76.00
|
| Rate for Payer: United Healthcare All Other HMO |
$76.00
|
| Rate for Payer: United Healthcare HMO Rider |
$76.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$76.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$129.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$129.20
|
| Rate for Payer: Vantage Medical Group Senior |
$129.20
|
|
|
SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]
|
Facility
OP
|
$300.49
|
|
|
Service Code
|
CPT Q2043
|
| Hospital Charge Code |
1753491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.12 |
| Max. Negotiated Rate |
$375,147.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$375,147.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$66,783.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$58,769.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$58,769.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$66,076.17
|
| Rate for Payer: BCBS Transplant Transplant |
$180.29
|
| Rate for Payer: Blue Shield of California Commercial |
$221.46
|
| Rate for Payer: Blue Shield of California EPN |
$75,123.02
|
| Rate for Payer: Cash Price |
$135.22
|
| Rate for Payer: Cash Price |
$135.22
|
| Rate for Payer: Cigna of CA HMO |
$210.34
|
| Rate for Payer: Cigna of CA PPO |
$210.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$80,139.98
|
| Rate for Payer: Dignity Health Media |
$53,426.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$58,769.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$72,125.99
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$53,426.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$53,426.66
|
| Rate for Payer: Galaxy Health WC |
$255.42
|
| Rate for Payer: Global Benefits Group Commercial |
$180.29
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$225.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$87,619.72
|
| Rate for Payer: Heritage Provider Network Transplant |
$87,619.72
|
| Rate for Payer: IEHP Medi-Cal |
$86,551.18
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$86,551.18
|
| Rate for Payer: IEHP Medicare Advantage |
$53,426.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$200.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$101,519.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$53,426.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$67,317.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$71,591.72
|
| Rate for Payer: Multiplan Commercial |
$240.39
|
| Rate for Payer: Networks By Design Commercial |
$150.24
|
| Rate for Payer: Prime Health Services Commercial |
$255.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$180.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$180.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$150.24
|
| Rate for Payer: United Healthcare All Other HMO |
$150.24
|
| Rate for Payer: United Healthcare HMO Rider |
$150.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$150.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$80,139.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$58,769.32
|
| Rate for Payer: Vantage Medical Group Senior |
$53,426.66
|
|
|
SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]
|
Facility
IP
|
$300.49
|
|
|
Service Code
|
CPT Q2043
|
| Hospital Charge Code |
1753491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.12 |
| Max. Negotiated Rate |
$255.42 |
| Rate for Payer: Blue Shield of California Commercial |
$213.95
|
| Rate for Payer: Blue Shield of California EPN |
$153.85
|
| Rate for Payer: Cash Price |
$135.22
|
| Rate for Payer: Cigna of CA HMO |
$210.34
|
| Rate for Payer: Cigna of CA PPO |
$210.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$120.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$120.20
|
| Rate for Payer: Galaxy Health WC |
$255.42
|
| Rate for Payer: Global Benefits Group Commercial |
$180.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$200.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$114.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.12
|
| Rate for Payer: Multiplan Commercial |
$240.39
|
| Rate for Payer: Networks By Design Commercial |
$150.24
|
| Rate for Payer: Prime Health Services Commercial |
$255.42
|
|
|
SIROLIMUS 0.5 MG TABLET [104764]
|
Facility
OP
|
$6.55
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1712518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$37.40 |
| Rate for Payer: BCBS Transplant Transplant |
$12.38
|
| Rate for Payer: BCBS Transplant Transplant |
$6.21
|
| Rate for Payer: BCBS Transplant Transplant |
$3.93
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.69
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.40
|
| Rate for Payer: Blue Shield of California Commercial |
$4.83
|
| Rate for Payer: Blue Shield of California Commercial |
$15.20
|
| Rate for Payer: Blue Shield of California Commercial |
$7.63
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Cigna of CA HMO |
$4.58
|
| Rate for Payer: Cigna of CA HMO |
$14.44
|
| Rate for Payer: Cigna of CA HMO |
$7.24
|
| Rate for Payer: Cigna of CA PPO |
$7.24
|
| Rate for Payer: Cigna of CA PPO |
$4.58
|
| Rate for Payer: Cigna of CA PPO |
$14.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.54
|
| Rate for Payer: Dignity Health Media |
$5.57
|
| Rate for Payer: Dignity Health Media |
$17.54
|
| Rate for Payer: Dignity Health Media |
$8.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.25
|
| Rate for Payer: Galaxy Health WC |
$17.54
|
| Rate for Payer: Galaxy Health WC |
$8.80
|
| Rate for Payer: Galaxy Health WC |
$5.57
|
| Rate for Payer: Global Benefits Group Commercial |
$3.93
|
| Rate for Payer: Global Benefits Group Commercial |
$12.38
|
| Rate for Payer: Global Benefits Group Commercial |
$6.21
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.91
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$15.47
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$7.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$8.28
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$16.50
|
| Rate for Payer: Networks By Design Commercial |
$10.32
|
| Rate for Payer: Networks By Design Commercial |
$3.28
|
| Rate for Payer: Networks By Design Commercial |
$5.18
|
| Rate for Payer: Prime Health Services Commercial |
$8.80
|
| Rate for Payer: Prime Health Services Commercial |
$5.57
|
| Rate for Payer: Prime Health Services Commercial |
$17.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.28
|
| Rate for Payer: United Healthcare All Other HMO |
$5.18
|
| Rate for Payer: United Healthcare All Other HMO |
$10.32
|
| Rate for Payer: United Healthcare All Other HMO |
$3.28
|
| Rate for Payer: United Healthcare HMO Rider |
$10.32
|
| Rate for Payer: United Healthcare HMO Rider |
$5.18
|
| Rate for Payer: United Healthcare HMO Rider |
$3.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.54
|
| Rate for Payer: Vantage Medical Group Senior |
$8.80
|
| Rate for Payer: Vantage Medical Group Senior |
$17.54
|
| Rate for Payer: Vantage Medical Group Senior |
$5.57
|
|
|
SIROLIMUS 0.5 MG TABLET [104764]
|
Facility
IP
|
$10.35
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1712518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$8.80 |
| Rate for Payer: Blue Shield of California Commercial |
$7.37
|
| Rate for Payer: Blue Shield of California Commercial |
$14.69
|
| Rate for Payer: Blue Shield of California Commercial |
$4.66
|
| Rate for Payer: Blue Shield of California EPN |
$3.35
|
| Rate for Payer: Blue Shield of California EPN |
$5.30
|
| Rate for Payer: Blue Shield of California EPN |
$10.56
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna of CA HMO |
$7.24
|
| Rate for Payer: Cigna of CA HMO |
$14.44
|
| Rate for Payer: Cigna of CA HMO |
$4.58
|
| Rate for Payer: Cigna of CA PPO |
$14.44
|
| Rate for Payer: Cigna of CA PPO |
$4.58
|
| Rate for Payer: Cigna of CA PPO |
$7.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.25
|
| Rate for Payer: Galaxy Health WC |
$8.80
|
| Rate for Payer: Galaxy Health WC |
$17.54
|
| Rate for Payer: Galaxy Health WC |
$5.57
|
| Rate for Payer: Global Benefits Group Commercial |
$12.38
|
| Rate for Payer: Global Benefits Group Commercial |
$6.21
|
| Rate for Payer: Global Benefits Group Commercial |
$3.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$8.28
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Networks By Design Commercial |
$3.28
|
| Rate for Payer: Networks By Design Commercial |
$10.32
|
| Rate for Payer: Networks By Design Commercial |
$5.18
|
| Rate for Payer: Prime Health Services Commercial |
$8.80
|
| Rate for Payer: Prime Health Services Commercial |
$17.54
|
| Rate for Payer: Prime Health Services Commercial |
$5.57
|
|
|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
IP
|
$21.05
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1715200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.05 |
| Max. Negotiated Rate |
$17.89 |
| Rate for Payer: Blue Shield of California Commercial |
$14.99
|
| Rate for Payer: Blue Shield of California Commercial |
$12.46
|
| Rate for Payer: Blue Shield of California EPN |
$8.96
|
| Rate for Payer: Blue Shield of California EPN |
$10.78
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cigna of CA HMO |
$14.74
|
| Rate for Payer: Cigna of CA HMO |
$12.25
|
| Rate for Payer: Cigna of CA PPO |
$14.74
|
| Rate for Payer: Cigna of CA PPO |
$12.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.00
|
| Rate for Payer: Galaxy Health WC |
$14.88
|
| Rate for Payer: Galaxy Health WC |
$17.89
|
| Rate for Payer: Global Benefits Group Commercial |
$10.50
|
| Rate for Payer: Global Benefits Group Commercial |
$12.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.05
|
| Rate for Payer: Multiplan Commercial |
$16.84
|
| Rate for Payer: Multiplan Commercial |
$14.00
|
| Rate for Payer: Networks By Design Commercial |
$8.75
|
| Rate for Payer: Networks By Design Commercial |
$10.52
|
| Rate for Payer: Prime Health Services Commercial |
$14.88
|
| Rate for Payer: Prime Health Services Commercial |
$17.89
|
|
|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
OP
|
$17.50
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1715200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$37.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.89
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.40
|
| Rate for Payer: BCBS Transplant Transplant |
$10.50
|
| Rate for Payer: BCBS Transplant Transplant |
$12.63
|
| Rate for Payer: Blue Shield of California Commercial |
$15.51
|
| Rate for Payer: Blue Shield of California Commercial |
$12.90
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cigna of CA HMO |
$12.25
|
| Rate for Payer: Cigna of CA HMO |
$14.74
|
| Rate for Payer: Cigna of CA PPO |
$12.25
|
| Rate for Payer: Cigna of CA PPO |
$14.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.89
|
| Rate for Payer: Dignity Health Media |
$14.88
|
| Rate for Payer: Dignity Health Media |
$17.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.00
|
| Rate for Payer: Galaxy Health WC |
$14.88
|
| Rate for Payer: Galaxy Health WC |
$17.89
|
| Rate for Payer: Global Benefits Group Commercial |
$10.50
|
| Rate for Payer: Global Benefits Group Commercial |
$12.63
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$15.79
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$13.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.05
|
| Rate for Payer: Multiplan Commercial |
$16.84
|
| Rate for Payer: Multiplan Commercial |
$14.00
|
| Rate for Payer: Networks By Design Commercial |
$8.75
|
| Rate for Payer: Networks By Design Commercial |
$10.52
|
| Rate for Payer: Prime Health Services Commercial |
$14.88
|
| Rate for Payer: Prime Health Services Commercial |
$17.89
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.75
|
| Rate for Payer: United Healthcare All Other HMO |
$10.52
|
| Rate for Payer: United Healthcare All Other HMO |
$8.75
|
| Rate for Payer: United Healthcare HMO Rider |
$10.52
|
| Rate for Payer: United Healthcare HMO Rider |
$8.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.89
|
| Rate for Payer: Vantage Medical Group Senior |
$14.88
|
| Rate for Payer: Vantage Medical Group Senior |
$17.89
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
IP
|
$16.66
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1711808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$14.16 |
| Rate for Payer: Blue Shield of California Commercial |
$11.86
|
| Rate for Payer: Blue Shield of California Commercial |
$6.41
|
| Rate for Payer: Blue Shield of California EPN |
$4.61
|
| Rate for Payer: Blue Shield of California EPN |
$8.53
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO |
$6.30
|
| Rate for Payer: Cigna of CA HMO |
$11.66
|
| Rate for Payer: Cigna of CA PPO |
$11.66
|
| Rate for Payer: Cigna of CA PPO |
$6.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.66
|
| Rate for Payer: Galaxy Health WC |
$14.16
|
| Rate for Payer: Galaxy Health WC |
$7.65
|
| Rate for Payer: Global Benefits Group Commercial |
$5.40
|
| Rate for Payer: Global Benefits Group Commercial |
$10.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.00
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: Multiplan Commercial |
$13.33
|
| Rate for Payer: Networks By Design Commercial |
$8.33
|
| Rate for Payer: Networks By Design Commercial |
$4.50
|
| Rate for Payer: Prime Health Services Commercial |
$7.65
|
| Rate for Payer: Prime Health Services Commercial |
$14.16
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
OP
|
$9.00
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1711808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$37.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.40
|
| Rate for Payer: BCBS Transplant Transplant |
$10.00
|
| Rate for Payer: BCBS Transplant Transplant |
$5.40
|
| Rate for Payer: Blue Shield of California Commercial |
$12.28
|
| Rate for Payer: Blue Shield of California Commercial |
$6.63
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO |
$11.66
|
| Rate for Payer: Cigna of CA HMO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$11.66
|
| Rate for Payer: Cigna of CA PPO |
$6.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.16
|
| Rate for Payer: Dignity Health Media |
$14.16
|
| Rate for Payer: Dignity Health Media |
$7.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.60
|
| Rate for Payer: Galaxy Health WC |
$7.65
|
| Rate for Payer: Galaxy Health WC |
$14.16
|
| Rate for Payer: Global Benefits Group Commercial |
$10.00
|
| Rate for Payer: Global Benefits Group Commercial |
$5.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$12.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.16
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: Multiplan Commercial |
$13.33
|
| Rate for Payer: Networks By Design Commercial |
$8.33
|
| Rate for Payer: Networks By Design Commercial |
$4.50
|
| Rate for Payer: Prime Health Services Commercial |
$7.65
|
| Rate for Payer: Prime Health Services Commercial |
$14.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$8.33
|
| Rate for Payer: United Healthcare All Other HMO |
$4.50
|
| Rate for Payer: United Healthcare HMO Rider |
$4.50
|
| Rate for Payer: United Healthcare HMO Rider |
$8.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.65
|
| Rate for Payer: Vantage Medical Group Senior |
$14.16
|
| Rate for Payer: Vantage Medical Group Senior |
$7.65
|
|
|
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION [233123]
|
Facility
OP
|
$8,512.06
|
|
|
Service Code
|
NDC 80803-153-50
|
| Hospital Charge Code |
ERX233123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,042.89 |
| Max. Negotiated Rate |
$7,235.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5,583.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,235.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,681.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,681.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,071.49
|
| Rate for Payer: BCBS Transplant Transplant |
$5,107.24
|
| Rate for Payer: Blue Shield of California Commercial |
$6,273.39
|
| Rate for Payer: Blue Shield of California EPN |
$4,971.04
|
| Rate for Payer: Cash Price |
$3,830.43
|
| Rate for Payer: Cash Price |
$3,830.43
|
| Rate for Payer: Cigna of CA HMO |
$5,958.44
|
| Rate for Payer: Cigna of CA PPO |
$5,958.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,235.25
|
| Rate for Payer: Dignity Health Media |
$7,235.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,235.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,404.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,404.82
|
| Rate for Payer: Galaxy Health WC |
$7,235.25
|
| Rate for Payer: Global Benefits Group Commercial |
$5,107.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6,384.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,677.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,243.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,042.89
|
| Rate for Payer: Multiplan Commercial |
$6,809.65
|
| Rate for Payer: Networks By Design Commercial |
$4,256.03
|
| Rate for Payer: Prime Health Services Commercial |
$7,235.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5,107.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5,107.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,256.03
|
| Rate for Payer: United Healthcare All Other HMO |
$4,256.03
|
| Rate for Payer: United Healthcare HMO Rider |
$4,256.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,256.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,235.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,235.25
|
| Rate for Payer: Vantage Medical Group Senior |
$7,235.25
|
|
|
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION [233123]
|
Facility
IP
|
$8,512.06
|
|
|
Service Code
|
NDC 80803-153-50
|
| Hospital Charge Code |
ERX233123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,042.89 |
| Max. Negotiated Rate |
$7,235.25 |
| Rate for Payer: Blue Shield of California Commercial |
$6,060.59
|
| Rate for Payer: Blue Shield of California EPN |
$4,358.17
|
| Rate for Payer: Cash Price |
$3,830.43
|
| Rate for Payer: Cigna of CA HMO |
$5,958.44
|
| Rate for Payer: Cigna of CA PPO |
$5,958.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,404.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,404.82
|
| Rate for Payer: Galaxy Health WC |
$7,235.25
|
| Rate for Payer: Global Benefits Group Commercial |
$5,107.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,677.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,243.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,042.89
|
| Rate for Payer: Multiplan Commercial |
$6,809.65
|
| Rate for Payer: Networks By Design Commercial |
$4,256.03
|
| Rate for Payer: Prime Health Services Commercial |
$7,235.25
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0277-31
|
| Hospital Charge Code |
1711892
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: BCBS Transplant Transplant |
$13.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$14.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.04
|
| Rate for Payer: Blue Shield of California Commercial |
$16.13
|
| Rate for Payer: Blue Shield of California EPN |
$12.78
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: Dignity Health Media |
$18.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$16.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0277-01
|
| Hospital Charge Code |
1711892
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.04
|
| Rate for Payer: BCBS Transplant Transplant |
$13.13
|
| Rate for Payer: Blue Shield of California Commercial |
$16.13
|
| Rate for Payer: Blue Shield of California EPN |
$12.78
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: Dignity Health Media |
$18.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$16.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0277-31
|
| Hospital Charge Code |
1711892
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Blue Shield of California Commercial |
$15.59
|
| Rate for Payer: Blue Shield of California EPN |
$11.21
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0277-01
|
| Hospital Charge Code |
1711892
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Blue Shield of California Commercial |
$15.59
|
| Rate for Payer: Blue Shield of California EPN |
$11.21
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0221-31
|
| Hospital Charge Code |
1711890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Blue Shield of California Commercial |
$15.59
|
| Rate for Payer: Blue Shield of California EPN |
$11.21
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0221-31
|
| Hospital Charge Code |
1711890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.04
|
| Rate for Payer: BCBS Transplant Transplant |
$13.13
|
| Rate for Payer: Blue Shield of California Commercial |
$16.13
|
| Rate for Payer: Blue Shield of California EPN |
$12.78
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: Dignity Health Media |
$18.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$16.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
