|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
|
OP
|
$21.05
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$44.83 |
| Rate for Payer: Adventist Health Commercial |
$4.21
|
| Rate for Payer: Adventist Health Commercial |
$2.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.83
|
| Rate for Payer: Blue Shield of California Commercial |
$11.77
|
| Rate for Payer: Blue Shield of California Commercial |
$11.77
|
| Rate for Payer: Cash Price |
$5.42
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cash Price |
$5.42
|
| Rate for Payer: Cigna of CA HMO |
$14.73
|
| Rate for Payer: Cigna of CA HMO |
$8.43
|
| Rate for Payer: Cigna of CA PPO |
$8.43
|
| Rate for Payer: Cigna of CA PPO |
$14.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$17.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$14.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.82
|
| Rate for Payer: EPIC Health Plan Senior |
$8.42
|
| Rate for Payer: EPIC Health Plan Senior |
$4.82
|
| Rate for Payer: Galaxy Health WC |
$17.89
|
| Rate for Payer: Galaxy Health WC |
$10.23
|
| Rate for Payer: Global Benefits Group Commercial |
$12.63
|
| Rate for Payer: Global Benefits Group Commercial |
$7.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$13.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$12.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.43
|
| Rate for Payer: Multiplan Commercial |
$16.84
|
| Rate for Payer: Multiplan Commercial |
$9.63
|
| Rate for Payer: Networks By Design Commercial |
$10.53
|
| Rate for Payer: Networks By Design Commercial |
$6.02
|
| Rate for Payer: Prime Health Services Commercial |
$10.23
|
| Rate for Payer: Prime Health Services Commercial |
$17.89
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.90
|
| Rate for Payer: United Healthcare All Other HMO |
$4.40
|
| Rate for Payer: United Healthcare All Other HMO |
$7.69
|
| Rate for Payer: United Healthcare HMO Rider |
$7.52
|
| Rate for Payer: United Healthcare HMO Rider |
$4.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.89
|
| Rate for Payer: Vantage Medical Group Senior |
$10.23
|
| Rate for Payer: Vantage Medical Group Senior |
$17.89
|
|
|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
|
IP
|
$21.05
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.21 |
| Max. Negotiated Rate |
$17.89 |
| Rate for Payer: Adventist Health Commercial |
$4.21
|
| Rate for Payer: Adventist Health Commercial |
$2.41
|
| Rate for Payer: Blue Shield of California Commercial |
$9.26
|
| Rate for Payer: Blue Shield of California Commercial |
$10.67
|
| Rate for Payer: Blue Shield of California Commercial |
$16.19
|
| Rate for Payer: Blue Shield of California Commercial |
$6.10
|
| Rate for Payer: Cash Price |
$5.42
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cigna of CA HMO |
$14.73
|
| Rate for Payer: Cigna of CA HMO |
$8.43
|
| Rate for Payer: Cigna of CA PPO |
$8.43
|
| Rate for Payer: Cigna of CA PPO |
$14.73
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$14.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: EPIC Health Plan Senior |
$4.82
|
| Rate for Payer: EPIC Health Plan Senior |
$8.42
|
| Rate for Payer: Galaxy Health WC |
$10.23
|
| Rate for Payer: Galaxy Health WC |
$17.89
|
| Rate for Payer: Global Benefits Group Commercial |
$12.63
|
| Rate for Payer: Global Benefits Group Commercial |
$7.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$13.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$12.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.05
|
| Rate for Payer: Multiplan Commercial |
$9.63
|
| Rate for Payer: Multiplan Commercial |
$16.84
|
| Rate for Payer: Networks By Design Commercial |
$10.53
|
| Rate for Payer: Networks By Design Commercial |
$6.02
|
| Rate for Payer: Prime Health Services Commercial |
$17.89
|
| Rate for Payer: Prime Health Services Commercial |
$10.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.90
|
| Rate for Payer: United Healthcare All Other HMO |
$7.69
|
| Rate for Payer: United Healthcare All Other HMO |
$4.40
|
| Rate for Payer: United Healthcare HMO Rider |
$4.30
|
| Rate for Payer: United Healthcare HMO Rider |
$7.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.89
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
|
OP
|
$5.40
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$44.83 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Adventist Health Commercial |
$3.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.83
|
| Rate for Payer: Blue Shield of California Commercial |
$11.77
|
| Rate for Payer: Blue Shield of California Commercial |
$11.77
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna of CA HMO |
$3.78
|
| 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 |
$3.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.66
|
| Rate for Payer: EPIC Health Plan Senior |
$2.16
|
| Rate for Payer: EPIC Health Plan Senior |
$6.66
|
| Rate for Payer: Galaxy Health WC |
$4.59
|
| Rate for Payer: Galaxy Health WC |
$14.16
|
| Rate for Payer: Global Benefits Group Commercial |
$3.24
|
| Rate for Payer: Global Benefits Group Commercial |
$10.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.66
|
| Rate for Payer: Multiplan Commercial |
$4.32
|
| Rate for Payer: Multiplan Commercial |
$13.33
|
| Rate for Payer: Networks By Design Commercial |
$2.70
|
| Rate for Payer: Networks By Design Commercial |
$8.33
|
| Rate for Payer: Prime Health Services Commercial |
$14.16
|
| Rate for Payer: Prime Health Services Commercial |
$4.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.03
|
| Rate for Payer: United Healthcare All Other HMO |
$6.09
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare HMO Rider |
$1.93
|
| Rate for Payer: United Healthcare HMO Rider |
$5.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.59
|
| 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 |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$14.16
|
| Rate for Payer: Vantage Medical Group Senior |
$4.59
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
|
IP
|
$5.40
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Adventist Health Commercial |
$3.33
|
| Rate for Payer: Blue Shield of California Commercial |
$8.45
|
| Rate for Payer: Blue Shield of California Commercial |
$2.74
|
| Rate for Payer: Blue Shield of California Commercial |
$4.15
|
| Rate for Payer: Blue Shield of California Commercial |
$12.81
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna of CA HMO |
$3.78
|
| 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 |
$3.78
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: EPIC Health Plan Senior |
$6.66
|
| Rate for Payer: EPIC Health Plan Senior |
$2.16
|
| Rate for Payer: Galaxy Health WC |
$14.16
|
| Rate for Payer: Galaxy Health WC |
$4.59
|
| Rate for Payer: Global Benefits Group Commercial |
$3.24
|
| Rate for Payer: Global Benefits Group Commercial |
$10.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$13.33
|
| Rate for Payer: Multiplan Commercial |
$4.32
|
| Rate for Payer: Networks By Design Commercial |
$2.70
|
| Rate for Payer: Networks By Design Commercial |
$8.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.59
|
| Rate for Payer: Prime Health Services Commercial |
$14.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.03
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$6.09
|
| Rate for Payer: United Healthcare HMO Rider |
$5.95
|
| Rate for Payer: United Healthcare HMO Rider |
$1.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.77
|
|
|
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION [233123]
|
Facility
|
IP
|
$10,614.40
|
|
|
Service Code
|
HCPCS J9331
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,122.88 |
| Max. Negotiated Rate |
$9,022.24 |
| Rate for Payer: Adventist Health Commercial |
$2,122.88
|
| Rate for Payer: Blue Shield of California Commercial |
$5,381.50
|
| Rate for Payer: Blue Shield of California Commercial |
$8,162.47
|
| Rate for Payer: Cash Price |
$4,776.48
|
| Rate for Payer: Cigna of CA HMO |
$7,430.08
|
| Rate for Payer: Cigna of CA PPO |
$7,430.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7,430.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,245.76
|
| Rate for Payer: EPIC Health Plan Senior |
$4,245.76
|
| Rate for Payer: Galaxy Health WC |
$9,022.24
|
| Rate for Payer: Global Benefits Group Commercial |
$6,368.64
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$6,740.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6,262.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,547.46
|
| Rate for Payer: Multiplan Commercial |
$8,491.52
|
| Rate for Payer: Networks By Design Commercial |
$5,307.20
|
| Rate for Payer: Prime Health Services Commercial |
$9,022.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,983.58
|
| Rate for Payer: United Healthcare All Other HMO |
$3,877.44
|
| Rate for Payer: United Healthcare HMO Rider |
$3,793.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,476.22
|
|
|
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION [233123]
|
Facility
|
OP
|
$10,614.40
|
|
|
Service Code
|
HCPCS J9331
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.03 |
| Max. Negotiated Rate |
$9,022.24 |
| Rate for Payer: Adventist Health Commercial |
$2,122.88
|
| Rate for Payer: Aetna of CA HMO/PPO |
$739.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$136.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$100.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$91.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$173.37
|
| Rate for Payer: Blue Shield of California Commercial |
$91.62
|
| Rate for Payer: Cash Price |
$4,776.48
|
| Rate for Payer: Cash Price |
$4,776.48
|
| Rate for Payer: Cigna of CA HMO |
$7,430.08
|
| Rate for Payer: Cigna of CA PPO |
$7,430.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$113.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$100.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$100.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7,430.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$150.20
|
| Rate for Payer: EPIC Health Plan Senior |
$100.13
|
| Rate for Payer: Galaxy Health WC |
$9,022.24
|
| Rate for Payer: Global Benefits Group Commercial |
$6,368.64
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$149.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$91.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$91.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$6,740.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$165.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$127.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,547.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$114.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$121.98
|
| Rate for Payer: Multiplan Commercial |
$8,491.52
|
| Rate for Payer: Networks By Design Commercial |
$5,307.20
|
| Rate for Payer: Prime Health Services Commercial |
$9,022.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6,368.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6,368.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,983.58
|
| Rate for Payer: United Healthcare All Other HMO |
$3,877.44
|
| Rate for Payer: United Healthcare HMO Rider |
$3,793.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,476.22
|
| Rate for Payer: Upland Medical Group Pediatric |
$91.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$113.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$100.13
|
| Rate for Payer: Vantage Medical Group Senior |
$100.13
|
|
|
SITAGLIPTIN 100 MG TABLET [240314]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 7071019013
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.77
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
SITAGLIPTIN 100 MG TABLET [240314]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 7071019013
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
SITAGLIPTIN 50 MG TABLET [240316]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 7071019003
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.77
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
SITAGLIPTIN 50 MG TABLET [240316]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 7071019003
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006027731
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California Commercial |
$10.15
|
| Rate for Payer: Blue Shield of California Commercial |
$6.69
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Multiplan Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006027731
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.47
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.60
|
| Rate for Payer: United Healthcare All Other HMO |
$6.60
|
| Rate for Payer: United Healthcare HMO Rider |
$6.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006027701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.47
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.60
|
| Rate for Payer: United Healthcare All Other HMO |
$6.60
|
| Rate for Payer: United Healthcare HMO Rider |
$6.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006027701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California Commercial |
$10.15
|
| Rate for Payer: Blue Shield of California Commercial |
$6.69
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Multiplan Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006022131
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California Commercial |
$10.15
|
| Rate for Payer: Blue Shield of California Commercial |
$6.69
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Multiplan Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006022131
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.47
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.60
|
| Rate for Payer: United Healthcare All Other HMO |
$6.60
|
| Rate for Payer: United Healthcare HMO Rider |
$6.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006011231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California Commercial |
$10.15
|
| Rate for Payer: Blue Shield of California Commercial |
$6.69
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Multiplan Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006011231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.47
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.60
|
| Rate for Payer: United Healthcare All Other HMO |
$6.60
|
| Rate for Payer: United Healthcare HMO Rider |
$6.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006011228
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.47
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.60
|
| Rate for Payer: United Healthcare All Other HMO |
$6.60
|
| Rate for Payer: United Healthcare HMO Rider |
$6.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006011228
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California Commercial |
$10.15
|
| Rate for Payer: Blue Shield of California Commercial |
$6.69
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Multiplan Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
|
|
SKIN DEBRIDEMENT WITH CC
|
Facility
|
IP
|
$109,229.49
|
|
|
Service Code
|
MSDRG 571
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$109,229.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$51,218.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$109,229.49
|
| Rate for Payer: EPIC Health Plan Senior |
$72,819.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$66,199.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$92,679.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$88,707.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
SKIN DEBRIDEMENT WITH MCC
|
Facility
|
IP
|
$131,438.92
|
|
|
Service Code
|
MSDRG 570
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$131,438.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$89,162.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$131,438.92
|
| Rate for Payer: EPIC Health Plan Senior |
$87,625.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$79,659.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$111,523.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$106,744.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
SKIN DEBRIDEMENT WITHOUT CC/MCC
|
Facility
|
IP
|
$99,590.50
|
|
|
Service Code
|
MSDRG 572
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$99,590.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$34,751.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$99,590.50
|
| Rate for Payer: EPIC Health Plan Senior |
$66,393.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$60,357.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$84,501.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$80,879.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC
|
Facility
|
IP
|
$126,285.82
|
|
|
Service Code
|
MSDRG 577
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$126,285.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$80,358.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$126,285.82
|
| Rate for Payer: EPIC Health Plan Senior |
$84,190.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$76,536.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$107,151.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$102,559.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC
|
Facility
|
IP
|
$166,220.55
|
|
|
Service Code
|
MSDRG 576
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$166,220.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$148,584.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$166,220.55
|
| Rate for Payer: EPIC Health Plan Senior |
$110,813.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$100,739.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$141,035.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$134,991.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
