|
SEIZURES WITHOUT MCC
|
Facility
|
IP
|
$95,266.10
|
|
|
Service Code
|
MSDRG 101
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$95,266.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27,363.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$95,266.10
|
| Rate for Payer: EPIC Health Plan Senior |
$63,510.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$57,737.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$80,831.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$77,367.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 6050500551
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.29
|
| 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 Medi-Cal |
$1.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.71
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Senior |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.71
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.41
|
| 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: 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 6050500551
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1.55
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Senior |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.71
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.19
|
| 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 7431203201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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 Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| 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: 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
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 4009310196
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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 Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| 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: 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 4009310196
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| 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 200 MCG TABLET [7139]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 7431203201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| 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 200 MCG TABLET [7139]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 7985401163
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| 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 200 MCG TABLET [7139]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 7985401163
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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 Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| 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: 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 50 MCG TABLET [7140]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 2689972174
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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 Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| 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: 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 2689972174
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.03
|
| 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
|
IP
|
$41.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.23 |
| Max. Negotiated Rate |
$34.99 |
| Rate for Payer: Adventist Health Commercial |
$8.23
|
| Rate for Payer: Blue Shield of California Commercial |
$20.87
|
| Rate for Payer: Blue Shield of California Commercial |
$31.65
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: Cigna of CA HMO |
$28.81
|
| Rate for Payer: Cigna of CA PPO |
$28.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$28.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.46
|
| Rate for Payer: EPIC Health Plan Senior |
$16.46
|
| Rate for Payer: Galaxy Health WC |
$34.99
|
| Rate for Payer: Global Benefits Group Commercial |
$24.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$26.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$24.28
|
| 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 |
$20.58
|
| Rate for Payer: Prime Health Services Commercial |
$34.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.45
|
| Rate for Payer: United Healthcare All Other HMO |
$15.04
|
| Rate for Payer: United Healthcare HMO Rider |
$14.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.48
|
|
|
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]
|
Facility
|
OP
|
$41.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.23 |
| Max. Negotiated Rate |
$34.99 |
| Rate for Payer: Adventist Health Commercial |
$8.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$34.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$30.87
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: Cigna of CA HMO |
$28.81
|
| Rate for Payer: Cigna of CA PPO |
$28.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$34.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$34.99
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$28.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.46
|
| Rate for Payer: EPIC Health Plan Senior |
$16.46
|
| Rate for Payer: Galaxy Health WC |
$34.99
|
| Rate for Payer: Global Benefits Group Commercial |
$24.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$26.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$24.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$28.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$28.81
|
| Rate for Payer: Multiplan Commercial |
$32.93
|
| Rate for Payer: Networks By Design Commercial |
$20.58
|
| 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 |
$15.45
|
| Rate for Payer: United Healthcare All Other HMO |
$15.04
|
| Rate for Payer: United Healthcare HMO Rider |
$14.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.48
|
| 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 SULFIDE 1 % SHAMPOO [38961]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0536199553
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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 Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| 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: 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
|
|
|
SELENIUM SULFIDE 1 % SHAMPOO [38961]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0536199553
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$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 2.25 % SHAMPOO [40158]
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 4219215206
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.53
|
| Rate for Payer: Cigna of CA PPO |
$0.53
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: EPIC Health Plan Senior |
$0.30
|
| Rate for Payer: Galaxy Health WC |
$0.64
|
| Rate for Payer: Global Benefits Group Commercial |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.49
|
| Rate for Payer: Prime Health Services Commercial |
$0.64
|
|
|
SELENIUM SULFIDE 2.25 % SHAMPOO [40158]
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 4219215206
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.48
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.53
|
| Rate for Payer: Cigna of CA PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.64
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: EPIC Health Plan Senior |
$0.30
|
| Rate for Payer: Galaxy Health WC |
$0.64
|
| Rate for Payer: Global Benefits Group Commercial |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.49
|
| Rate for Payer: Prime Health Services Commercial |
$0.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.38
|
| Rate for Payer: United Healthcare All Other HMO |
$0.38
|
| Rate for Payer: United Healthcare HMO Rider |
$0.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
|
|
SELEXIPAG 200 MCG TABLET [212415]
|
Facility
|
IP
|
$311.57
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.31 |
| Max. Negotiated Rate |
$264.83 |
| Rate for Payer: Adventist Health Commercial |
$62.31
|
| Rate for Payer: Blue Shield of California Commercial |
$157.97
|
| Rate for Payer: Blue Shield of California Commercial |
$239.60
|
| Rate for Payer: Cash Price |
$140.21
|
| Rate for Payer: Cigna of CA HMO |
$218.10
|
| Rate for Payer: Cigna of CA PPO |
$218.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$218.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$124.63
|
| Rate for Payer: EPIC Health Plan Senior |
$124.63
|
| Rate for Payer: Galaxy Health WC |
$264.83
|
| Rate for Payer: Global Benefits Group Commercial |
$186.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$197.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$183.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$74.78
|
| Rate for Payer: Multiplan Commercial |
$249.26
|
| Rate for Payer: Networks By Design Commercial |
$155.78
|
| Rate for Payer: Prime Health Services Commercial |
$264.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$116.93
|
| Rate for Payer: United Healthcare All Other HMO |
$113.82
|
| Rate for Payer: United Healthcare HMO Rider |
$111.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$102.04
|
|
|
SELEXIPAG 200 MCG TABLET [212415]
|
Facility
|
OP
|
$311.57
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.31 |
| Max. Negotiated Rate |
$264.83 |
| Rate for Payer: Adventist Health Commercial |
$62.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$204.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$264.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$171.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$233.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$199.93
|
| Rate for Payer: Cash Price |
$140.21
|
| Rate for Payer: Cigna of CA HMO |
$218.10
|
| Rate for Payer: Cigna of CA PPO |
$218.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$264.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$264.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$264.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$218.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$124.63
|
| Rate for Payer: EPIC Health Plan Senior |
$124.63
|
| Rate for Payer: Galaxy Health WC |
$264.83
|
| Rate for Payer: Global Benefits Group Commercial |
$186.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$197.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$113.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$183.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$74.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$218.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$218.10
|
| Rate for Payer: Multiplan Commercial |
$249.26
|
| Rate for Payer: Networks By Design Commercial |
$155.78
|
| Rate for Payer: Prime Health Services Commercial |
$264.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$186.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$186.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$116.93
|
| Rate for Payer: United Healthcare All Other HMO |
$113.82
|
| Rate for Payer: United Healthcare HMO Rider |
$111.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$102.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$264.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$264.83
|
| Rate for Payer: Vantage Medical Group Senior |
$264.83
|
|
|
SELEXIPAG 400 MCG TABLET [212416]
|
Facility
|
OP
|
$484.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.91 |
| Max. Negotiated Rate |
$411.86 |
| Rate for Payer: Adventist Health Commercial |
$96.91
|
| Rate for Payer: Aetna of CA HMO/PPO |
$317.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$411.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$266.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$363.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$310.93
|
| Rate for Payer: Cash Price |
$218.04
|
| Rate for Payer: Cigna of CA HMO |
$339.18
|
| Rate for Payer: Cigna of CA PPO |
$339.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$411.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$411.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$411.86
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$339.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$193.82
|
| Rate for Payer: EPIC Health Plan Senior |
$193.82
|
| Rate for Payer: Galaxy Health WC |
$411.86
|
| Rate for Payer: Global Benefits Group Commercial |
$290.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$307.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$175.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$285.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$339.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$339.18
|
| Rate for Payer: Multiplan Commercial |
$387.63
|
| Rate for Payer: Networks By Design Commercial |
$242.27
|
| Rate for Payer: Prime Health Services Commercial |
$411.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$290.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$290.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$181.85
|
| Rate for Payer: United Healthcare All Other HMO |
$177.00
|
| Rate for Payer: United Healthcare HMO Rider |
$173.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$158.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$411.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$411.86
|
| Rate for Payer: Vantage Medical Group Senior |
$411.86
|
|
|
SELEXIPAG 400 MCG TABLET [212416]
|
Facility
|
IP
|
$484.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.91 |
| Max. Negotiated Rate |
$411.86 |
| Rate for Payer: Adventist Health Commercial |
$96.91
|
| Rate for Payer: Blue Shield of California Commercial |
$245.66
|
| Rate for Payer: Blue Shield of California Commercial |
$372.61
|
| Rate for Payer: Cash Price |
$218.04
|
| Rate for Payer: Cigna of CA HMO |
$339.18
|
| Rate for Payer: Cigna of CA PPO |
$339.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$339.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$193.82
|
| Rate for Payer: EPIC Health Plan Senior |
$193.82
|
| Rate for Payer: Galaxy Health WC |
$411.86
|
| Rate for Payer: Global Benefits Group Commercial |
$290.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$307.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$285.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.29
|
| Rate for Payer: Multiplan Commercial |
$387.63
|
| Rate for Payer: Networks By Design Commercial |
$242.27
|
| Rate for Payer: Prime Health Services Commercial |
$411.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$181.85
|
| Rate for Payer: United Healthcare All Other HMO |
$177.00
|
| Rate for Payer: United Healthcare HMO Rider |
$173.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$158.69
|
|
|
SELEXIPAG 800 MCG TABLET [212418]
|
Facility
|
IP
|
$484.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700030
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$96.91 |
| Max. Negotiated Rate |
$411.86 |
| Rate for Payer: Adventist Health Commercial |
$96.91
|
| Rate for Payer: Blue Shield of California Commercial |
$245.66
|
| Rate for Payer: Blue Shield of California Commercial |
$372.61
|
| Rate for Payer: Cash Price |
$218.04
|
| Rate for Payer: Cigna of CA HMO |
$339.18
|
| Rate for Payer: Cigna of CA PPO |
$339.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$339.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$193.82
|
| Rate for Payer: EPIC Health Plan Senior |
$193.82
|
| Rate for Payer: Galaxy Health WC |
$411.86
|
| Rate for Payer: Global Benefits Group Commercial |
$290.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$307.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$285.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.29
|
| Rate for Payer: Multiplan Commercial |
$387.63
|
| Rate for Payer: Networks By Design Commercial |
$314.95
|
| Rate for Payer: Prime Health Services Commercial |
$411.86
|
|
|
SELEXIPAG 800 MCG TABLET [212418]
|
Facility
|
OP
|
$484.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700030
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$96.91 |
| Max. Negotiated Rate |
$411.86 |
| Rate for Payer: Adventist Health Commercial |
$96.91
|
| Rate for Payer: Aetna of CA HMO/PPO |
$317.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$411.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$266.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$363.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$310.93
|
| Rate for Payer: Cash Price |
$218.04
|
| Rate for Payer: Cigna of CA HMO |
$339.18
|
| Rate for Payer: Cigna of CA PPO |
$339.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$411.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$411.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$411.86
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$339.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$193.82
|
| Rate for Payer: EPIC Health Plan Senior |
$193.82
|
| Rate for Payer: Galaxy Health WC |
$411.86
|
| Rate for Payer: Global Benefits Group Commercial |
$290.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$307.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$175.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$285.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$339.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$339.18
|
| Rate for Payer: Multiplan Commercial |
$387.63
|
| Rate for Payer: Networks By Design Commercial |
$314.95
|
| Rate for Payer: Prime Health Services Commercial |
$411.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$290.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$290.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$242.27
|
| Rate for Payer: United Healthcare All Other HMO |
$242.27
|
| Rate for Payer: United Healthcare HMO Rider |
$242.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$242.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$411.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$411.86
|
| Rate for Payer: Vantage Medical Group Senior |
$411.86
|
|
|
SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP [117388]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0121072208
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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 Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| 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: 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
|
|
|
SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP [117388]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0121072208
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| 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
|
|
