|
RUFINAMIDE 40 MG/ML ORAL SUSPENSION [108804]
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
NDC 62856-584-46
|
| Hospital Charge Code |
1715258
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.73
|
| Rate for Payer: Blue Distinction Transplant |
$2.75
|
| Rate for Payer: Blue Shield of California Commercial |
$3.38
|
| Rate for Payer: Blue Shield of California EPN |
$2.68
|
| Rate for Payer: Cash Price |
$2.07
|
| Rate for Payer: Cigna of CA HMO |
$3.21
|
| Rate for Payer: Cigna of CA PPO |
$3.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.90
|
| Rate for Payer: Dignity Health Media |
$3.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.84
|
| Rate for Payer: Galaxy Health WC |
$3.90
|
| Rate for Payer: Global Benefits Group Commercial |
$2.75
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$3.67
|
| Rate for Payer: Networks By Design Commercial |
$2.98
|
| Rate for Payer: Prime Health Services Commercial |
$3.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.75
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.30
|
| Rate for Payer: United Healthcare All Other HMO |
$2.30
|
| Rate for Payer: United Healthcare HMO Rider |
$2.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.90
|
| Rate for Payer: Vantage Medical Group Senior |
$3.90
|
|
|
RUXOLITINIB 10 MG TABLET [153887]
|
Facility
|
IP
|
$333.72
|
|
|
Service Code
|
NDC 50881-010-60
|
| Hospital Charge Code |
ERX153887
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.09 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Blue Shield of California Commercial |
$237.61
|
| Rate for Payer: Blue Shield of California EPN |
$170.86
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO |
$233.60
|
| Rate for Payer: Cigna of CA PPO |
$233.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.49
|
| Rate for Payer: Galaxy Health WC |
$283.66
|
| Rate for Payer: Global Benefits Group Commercial |
$200.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$222.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.09
|
| Rate for Payer: Multiplan Commercial |
$266.98
|
| Rate for Payer: Networks By Design Commercial |
$216.92
|
| Rate for Payer: Prime Health Services Commercial |
$283.66
|
|
|
RUXOLITINIB 10 MG TABLET [153887]
|
Facility
|
OP
|
$333.72
|
|
|
Service Code
|
NDC 50881-010-60
|
| Hospital Charge Code |
ERX153887
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.09 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$218.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$183.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$183.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$198.83
|
| Rate for Payer: Blue Distinction Transplant |
$200.23
|
| Rate for Payer: Blue Shield of California Commercial |
$245.95
|
| Rate for Payer: Blue Shield of California EPN |
$194.89
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO |
$233.60
|
| Rate for Payer: Cigna of CA PPO |
$233.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$283.66
|
| Rate for Payer: Dignity Health Media |
$283.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$283.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$133.49
|
| Rate for Payer: Galaxy Health WC |
$283.66
|
| Rate for Payer: Global Benefits Group Commercial |
$200.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$250.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$222.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.09
|
| Rate for Payer: Multiplan Commercial |
$266.98
|
| Rate for Payer: Networks By Design Commercial |
$216.92
|
| Rate for Payer: Prime Health Services Commercial |
$283.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$200.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$200.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$166.86
|
| Rate for Payer: United Healthcare All Other HMO |
$166.86
|
| Rate for Payer: United Healthcare HMO Rider |
$166.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$166.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$283.66
|
| Rate for Payer: Vantage Medical Group Senior |
$283.66
|
|
|
RUXOLITINIB 15 MG TABLET [153888]
|
Facility
|
OP
|
$333.72
|
|
|
Service Code
|
NDC 50881-015-60
|
| Hospital Charge Code |
ERX153888
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.09 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$218.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$183.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$183.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$198.83
|
| Rate for Payer: Blue Distinction Transplant |
$200.23
|
| Rate for Payer: Blue Shield of California Commercial |
$245.95
|
| Rate for Payer: Blue Shield of California EPN |
$194.89
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO |
$233.60
|
| Rate for Payer: Cigna of CA PPO |
$233.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$283.66
|
| Rate for Payer: Dignity Health Media |
$283.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$283.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$133.49
|
| Rate for Payer: Galaxy Health WC |
$283.66
|
| Rate for Payer: Global Benefits Group Commercial |
$200.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$250.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$222.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.09
|
| Rate for Payer: Multiplan Commercial |
$266.98
|
| Rate for Payer: Networks By Design Commercial |
$216.92
|
| Rate for Payer: Prime Health Services Commercial |
$283.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$200.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$200.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$166.86
|
| Rate for Payer: United Healthcare All Other HMO |
$166.86
|
| Rate for Payer: United Healthcare HMO Rider |
$166.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$166.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$283.66
|
| Rate for Payer: Vantage Medical Group Senior |
$283.66
|
|
|
RUXOLITINIB 15 MG TABLET [153888]
|
Facility
|
IP
|
$333.72
|
|
|
Service Code
|
NDC 50881-015-60
|
| Hospital Charge Code |
ERX153888
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.09 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Blue Shield of California Commercial |
$237.61
|
| Rate for Payer: Blue Shield of California EPN |
$170.86
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO |
$233.60
|
| Rate for Payer: Cigna of CA PPO |
$233.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.49
|
| Rate for Payer: Galaxy Health WC |
$283.66
|
| Rate for Payer: Global Benefits Group Commercial |
$200.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$222.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.09
|
| Rate for Payer: Multiplan Commercial |
$266.98
|
| Rate for Payer: Networks By Design Commercial |
$216.92
|
| Rate for Payer: Prime Health Services Commercial |
$283.66
|
|
|
RUXOLITINIB 20 MG TABLET [153889]
|
Facility
|
OP
|
$333.72
|
|
|
Service Code
|
NDC 50881-020-60
|
| Hospital Charge Code |
ERX153889
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.09 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$218.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$183.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$183.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$198.83
|
| Rate for Payer: Blue Distinction Transplant |
$200.23
|
| Rate for Payer: Blue Shield of California Commercial |
$245.95
|
| Rate for Payer: Blue Shield of California EPN |
$194.89
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO |
$233.60
|
| Rate for Payer: Cigna of CA PPO |
$233.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$283.66
|
| Rate for Payer: Dignity Health Media |
$283.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$283.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$133.49
|
| Rate for Payer: Galaxy Health WC |
$283.66
|
| Rate for Payer: Global Benefits Group Commercial |
$200.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$250.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$222.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.09
|
| Rate for Payer: Multiplan Commercial |
$266.98
|
| Rate for Payer: Networks By Design Commercial |
$216.92
|
| Rate for Payer: Prime Health Services Commercial |
$283.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$200.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$200.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$166.86
|
| Rate for Payer: United Healthcare All Other HMO |
$166.86
|
| Rate for Payer: United Healthcare HMO Rider |
$166.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$166.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$283.66
|
| Rate for Payer: Vantage Medical Group Senior |
$283.66
|
|
|
RUXOLITINIB 20 MG TABLET [153889]
|
Facility
|
IP
|
$333.72
|
|
|
Service Code
|
NDC 50881-020-60
|
| Hospital Charge Code |
ERX153889
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.09 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Blue Shield of California Commercial |
$237.61
|
| Rate for Payer: Blue Shield of California EPN |
$170.86
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO |
$233.60
|
| Rate for Payer: Cigna of CA PPO |
$233.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.49
|
| Rate for Payer: Galaxy Health WC |
$283.66
|
| Rate for Payer: Global Benefits Group Commercial |
$200.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$222.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.09
|
| Rate for Payer: Multiplan Commercial |
$266.98
|
| Rate for Payer: Networks By Design Commercial |
$216.92
|
| Rate for Payer: Prime Health Services Commercial |
$283.66
|
|
|
RUXOLITINIB 25 MG TABLET [153890]
|
Facility
|
IP
|
$333.72
|
|
|
Service Code
|
NDC 50881-025-60
|
| Hospital Charge Code |
ERX153890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.09 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Blue Shield of California Commercial |
$237.61
|
| Rate for Payer: Blue Shield of California EPN |
$170.86
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO |
$233.60
|
| Rate for Payer: Cigna of CA PPO |
$233.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.49
|
| Rate for Payer: Galaxy Health WC |
$283.66
|
| Rate for Payer: Global Benefits Group Commercial |
$200.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$222.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.09
|
| Rate for Payer: Multiplan Commercial |
$266.98
|
| Rate for Payer: Networks By Design Commercial |
$216.92
|
| Rate for Payer: Prime Health Services Commercial |
$283.66
|
|
|
RUXOLITINIB 25 MG TABLET [153890]
|
Facility
|
OP
|
$333.72
|
|
|
Service Code
|
NDC 50881-025-60
|
| Hospital Charge Code |
ERX153890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.09 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$218.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$183.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$183.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$198.83
|
| Rate for Payer: Blue Distinction Transplant |
$200.23
|
| Rate for Payer: Blue Shield of California Commercial |
$245.95
|
| Rate for Payer: Blue Shield of California EPN |
$194.89
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO |
$233.60
|
| Rate for Payer: Cigna of CA PPO |
$233.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$283.66
|
| Rate for Payer: Dignity Health Media |
$283.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$283.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$133.49
|
| Rate for Payer: Galaxy Health WC |
$283.66
|
| Rate for Payer: Global Benefits Group Commercial |
$200.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$250.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$222.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.09
|
| Rate for Payer: Multiplan Commercial |
$266.98
|
| Rate for Payer: Networks By Design Commercial |
$216.92
|
| Rate for Payer: Prime Health Services Commercial |
$283.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$200.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$200.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$166.86
|
| Rate for Payer: United Healthcare All Other HMO |
$166.86
|
| Rate for Payer: United Healthcare HMO Rider |
$166.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$166.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$283.66
|
| Rate for Payer: Vantage Medical Group Senior |
$283.66
|
|
|
RUXOLITINIB 5 MG TABLET [153886]
|
Facility
|
IP
|
$333.72
|
|
|
Service Code
|
NDC 50881-005-60
|
| Hospital Charge Code |
ERX153886
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.09 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Blue Shield of California Commercial |
$237.61
|
| Rate for Payer: Blue Shield of California EPN |
$170.86
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO |
$233.60
|
| Rate for Payer: Cigna of CA PPO |
$233.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.49
|
| Rate for Payer: Galaxy Health WC |
$283.66
|
| Rate for Payer: Global Benefits Group Commercial |
$200.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$222.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.09
|
| Rate for Payer: Multiplan Commercial |
$266.98
|
| Rate for Payer: Networks By Design Commercial |
$216.92
|
| Rate for Payer: Prime Health Services Commercial |
$283.66
|
|
|
RUXOLITINIB 5 MG TABLET [153886]
|
Facility
|
OP
|
$333.72
|
|
|
Service Code
|
NDC 50881-005-60
|
| Hospital Charge Code |
ERX153886
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.09 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$218.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$183.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$183.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$198.83
|
| Rate for Payer: Blue Distinction Transplant |
$200.23
|
| Rate for Payer: Blue Shield of California Commercial |
$245.95
|
| Rate for Payer: Blue Shield of California EPN |
$194.89
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO |
$233.60
|
| Rate for Payer: Cigna of CA PPO |
$233.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$283.66
|
| Rate for Payer: Dignity Health Media |
$283.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$283.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$133.49
|
| Rate for Payer: Galaxy Health WC |
$283.66
|
| Rate for Payer: Global Benefits Group Commercial |
$200.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$250.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$222.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.09
|
| Rate for Payer: Multiplan Commercial |
$266.98
|
| Rate for Payer: Networks By Design Commercial |
$216.92
|
| Rate for Payer: Prime Health Services Commercial |
$283.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$200.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$200.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$166.86
|
| Rate for Payer: United Healthcare All Other HMO |
$166.86
|
| Rate for Payer: United Healthcare HMO Rider |
$166.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$166.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$283.66
|
| Rate for Payer: Vantage Medical Group Senior |
$283.66
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [227764]
|
Facility
|
IP
|
$2,814.28
|
|
|
Service Code
|
NDC 55135-132-01
|
| Hospital Charge Code |
ERX227764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$675.43 |
| Max. Negotiated Rate |
$2,392.14 |
| Rate for Payer: Blue Shield of California Commercial |
$2,003.77
|
| Rate for Payer: Blue Shield of California EPN |
$1,440.91
|
| Rate for Payer: Cash Price |
$1,266.43
|
| Rate for Payer: Cigna of CA HMO |
$1,970.00
|
| Rate for Payer: Cigna of CA PPO |
$1,970.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,125.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,125.71
|
| Rate for Payer: Galaxy Health WC |
$2,392.14
|
| Rate for Payer: Global Benefits Group Commercial |
$1,688.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,877.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,072.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$675.43
|
| Rate for Payer: Multiplan Commercial |
$2,251.42
|
| Rate for Payer: Networks By Design Commercial |
$1,407.14
|
| Rate for Payer: Prime Health Services Commercial |
$2,392.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,062.67
|
| Rate for Payer: United Healthcare All Other HMO |
$1,037.91
|
| Rate for Payer: United Healthcare HMO Rider |
$1,015.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$928.71
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [227764]
|
Facility
|
OP
|
$2,814.28
|
|
|
Service Code
|
NDC 55135-132-01
|
| Hospital Charge Code |
ERX227764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$675.43 |
| Max. Negotiated Rate |
$2,392.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,845.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,392.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,547.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,547.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,676.75
|
| Rate for Payer: Blue Distinction Transplant |
$1,688.57
|
| Rate for Payer: Blue Shield of California Commercial |
$2,074.12
|
| Rate for Payer: Blue Shield of California EPN |
$1,643.54
|
| Rate for Payer: Cash Price |
$1,266.43
|
| Rate for Payer: Cigna of CA HMO |
$1,970.00
|
| Rate for Payer: Cigna of CA PPO |
$1,970.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,392.14
|
| Rate for Payer: Dignity Health Media |
$2,392.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,392.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,125.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,125.71
|
| Rate for Payer: Galaxy Health WC |
$2,392.14
|
| Rate for Payer: Global Benefits Group Commercial |
$1,688.57
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2,110.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,877.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,072.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$675.43
|
| Rate for Payer: Multiplan Commercial |
$2,251.42
|
| Rate for Payer: Networks By Design Commercial |
$1,407.14
|
| Rate for Payer: Prime Health Services Commercial |
$2,392.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,688.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,688.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,407.14
|
| Rate for Payer: United Healthcare All Other HMO |
$1,407.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1,407.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,407.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,392.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,392.14
|
| Rate for Payer: Vantage Medical Group Senior |
$2,392.14
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
OP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0659-20
|
| Hospital Charge Code |
ERX210397
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$8.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.96
|
| Rate for Payer: Blue Distinction Transplant |
$8.02
|
| Rate for Payer: Blue Shield of California Commercial |
$9.85
|
| Rate for Payer: Blue Shield of California EPN |
$7.80
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: Cigna of CA HMO |
$9.35
|
| Rate for Payer: Cigna of CA PPO |
$9.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.36
|
| Rate for Payer: Dignity Health Media |
$11.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.34
|
| Rate for Payer: Galaxy Health WC |
$11.36
|
| Rate for Payer: Global Benefits Group Commercial |
$8.02
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$10.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$10.69
|
| Rate for Payer: Networks By Design Commercial |
$8.68
|
| Rate for Payer: Prime Health Services Commercial |
$11.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.68
|
| Rate for Payer: United Healthcare All Other HMO |
$6.68
|
| Rate for Payer: United Healthcare HMO Rider |
$6.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.36
|
| Rate for Payer: Vantage Medical Group Senior |
$11.36
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
IP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0659-20
|
| Hospital Charge Code |
ERX210397
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Blue Shield of California Commercial |
$9.51
|
| Rate for Payer: Blue Shield of California EPN |
$6.84
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: Cigna of CA HMO |
$9.35
|
| Rate for Payer: Cigna of CA PPO |
$9.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.34
|
| Rate for Payer: Galaxy Health WC |
$11.36
|
| Rate for Payer: Global Benefits Group Commercial |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$10.69
|
| Rate for Payer: Networks By Design Commercial |
$8.68
|
| Rate for Payer: Prime Health Services Commercial |
$11.36
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
OP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0777-20
|
| Hospital Charge Code |
ERX210398
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$8.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.96
|
| Rate for Payer: Blue Distinction Transplant |
$8.02
|
| Rate for Payer: Blue Shield of California Commercial |
$9.85
|
| Rate for Payer: Blue Shield of California EPN |
$7.80
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: Cigna of CA HMO |
$9.35
|
| Rate for Payer: Cigna of CA PPO |
$9.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.36
|
| Rate for Payer: Dignity Health Media |
$11.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.34
|
| Rate for Payer: Galaxy Health WC |
$11.36
|
| Rate for Payer: Global Benefits Group Commercial |
$8.02
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$10.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$10.69
|
| Rate for Payer: Networks By Design Commercial |
$8.68
|
| Rate for Payer: Prime Health Services Commercial |
$11.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.68
|
| Rate for Payer: United Healthcare All Other HMO |
$6.68
|
| Rate for Payer: United Healthcare HMO Rider |
$6.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.36
|
| Rate for Payer: Vantage Medical Group Senior |
$11.36
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
IP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0777-20
|
| Hospital Charge Code |
ERX210398
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Blue Shield of California Commercial |
$9.51
|
| Rate for Payer: Blue Shield of California EPN |
$6.84
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: Cigna of CA HMO |
$9.35
|
| Rate for Payer: Cigna of CA PPO |
$9.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.34
|
| Rate for Payer: Galaxy Health WC |
$11.36
|
| Rate for Payer: Global Benefits Group Commercial |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$10.69
|
| Rate for Payer: Networks By Design Commercial |
$8.68
|
| Rate for Payer: Prime Health Services Commercial |
$11.36
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
OP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0696-20
|
| Hospital Charge Code |
ERX210399
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$8.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.96
|
| Rate for Payer: Blue Distinction Transplant |
$8.02
|
| Rate for Payer: Blue Shield of California Commercial |
$9.85
|
| Rate for Payer: Blue Shield of California EPN |
$7.80
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: Cigna of CA HMO |
$9.35
|
| Rate for Payer: Cigna of CA PPO |
$9.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.36
|
| Rate for Payer: Dignity Health Media |
$11.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.34
|
| Rate for Payer: Galaxy Health WC |
$11.36
|
| Rate for Payer: Global Benefits Group Commercial |
$8.02
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$10.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$10.69
|
| Rate for Payer: Networks By Design Commercial |
$8.68
|
| Rate for Payer: Prime Health Services Commercial |
$11.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.68
|
| Rate for Payer: United Healthcare All Other HMO |
$6.68
|
| Rate for Payer: United Healthcare HMO Rider |
$6.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.36
|
| Rate for Payer: Vantage Medical Group Senior |
$11.36
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
IP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0696-20
|
| Hospital Charge Code |
ERX210399
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Blue Shield of California Commercial |
$9.51
|
| Rate for Payer: Blue Shield of California EPN |
$6.84
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: Cigna of CA HMO |
$9.35
|
| Rate for Payer: Cigna of CA PPO |
$9.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.34
|
| Rate for Payer: Galaxy Health WC |
$11.36
|
| Rate for Payer: Global Benefits Group Commercial |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$10.69
|
| Rate for Payer: Networks By Design Commercial |
$8.68
|
| Rate for Payer: Prime Health Services Commercial |
$11.36
|
|
|
SALICYLIC ACID 17 % TOPICAL LIQUID [11323]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 1101725220
|
| Hospital Charge Code |
NDG11323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: Blue Distinction Transplant |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Media |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
SALICYLIC ACID 17 % TOPICAL LIQUID [11323]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 1101725220
|
| Hospital Charge Code |
NDG11323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
|
|
SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 4858251201
|
| Hospital Charge Code |
NDG216603
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 4858251201
|
| Hospital Charge Code |
NDG216603
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 6014629157
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Blue Distinction Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Media |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 8489800001
|
| Hospital Charge Code |
1719220
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Blue Distinction Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Media |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
