|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
|
IP
|
$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: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| 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: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| 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
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 73090-0800-02
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Distinction Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Media |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 73090-0800-02
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
|
IP
|
$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: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| 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: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| 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
|
|
|
SAQUINAVIR 500 MG TABLET [40401]
|
Facility
|
OP
|
$12.02
|
|
|
Service Code
|
NDC 0004-0244-51
|
| Hospital Charge Code |
1710991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$10.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.16
|
| Rate for Payer: Blue Distinction Transplant |
$7.21
|
| Rate for Payer: Blue Shield of California Commercial |
$8.86
|
| Rate for Payer: Blue Shield of California EPN |
$7.02
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: Cigna of CA HMO |
$8.41
|
| Rate for Payer: Cigna of CA PPO |
$8.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.22
|
| Rate for Payer: Dignity Health Media |
$10.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.81
|
| Rate for Payer: Galaxy Health WC |
$10.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.21
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$9.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$9.62
|
| Rate for Payer: Networks By Design Commercial |
$7.81
|
| Rate for Payer: Prime Health Services Commercial |
$10.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.01
|
| Rate for Payer: United Healthcare All Other HMO |
$6.01
|
| Rate for Payer: United Healthcare HMO Rider |
$6.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.22
|
| Rate for Payer: Vantage Medical Group Senior |
$10.22
|
|
|
SAQUINAVIR 500 MG TABLET [40401]
|
Facility
|
IP
|
$12.02
|
|
|
Service Code
|
NDC 0004-0244-51
|
| Hospital Charge Code |
1710991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$10.22 |
| Rate for Payer: Blue Shield of California Commercial |
$8.56
|
| Rate for Payer: Blue Shield of California EPN |
$6.15
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: Cigna of CA HMO |
$8.41
|
| Rate for Payer: Cigna of CA PPO |
$8.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.81
|
| Rate for Payer: Galaxy Health WC |
$10.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$9.62
|
| Rate for Payer: Networks By Design Commercial |
$7.81
|
| Rate for Payer: Prime Health Services Commercial |
$10.22
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS PEN INJECTOR [221911]
|
Facility
|
OP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG221911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$517.55 |
| Max. Negotiated Rate |
$1,832.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,414.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,832.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,186.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,186.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,284.82
|
| Rate for Payer: Blue Distinction Transplant |
$1,293.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1,589.31
|
| Rate for Payer: Blue Shield of California EPN |
$1,259.37
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cigna of CA HMO |
$1,509.52
|
| Rate for Payer: Cigna of CA PPO |
$1,509.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,832.99
|
| Rate for Payer: Dignity Health Media |
$1,832.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,832.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$862.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$862.58
|
| Rate for Payer: Galaxy Health WC |
$1,832.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1,293.88
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,617.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,438.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$821.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$517.55
|
| Rate for Payer: Multiplan Commercial |
$1,725.17
|
| Rate for Payer: Networks By Design Commercial |
$1,078.23
|
| Rate for Payer: Prime Health Services Commercial |
$1,832.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,293.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,293.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,078.23
|
| Rate for Payer: United Healthcare All Other HMO |
$1,078.23
|
| Rate for Payer: United Healthcare HMO Rider |
$1,078.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,078.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,832.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,832.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1,832.99
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS PEN INJECTOR [221911]
|
Facility
|
IP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG221911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$517.55 |
| Max. Negotiated Rate |
$1,832.99 |
| Rate for Payer: Blue Shield of California Commercial |
$1,535.40
|
| Rate for Payer: Blue Shield of California EPN |
$1,104.11
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cigna of CA HMO |
$1,509.52
|
| Rate for Payer: Cigna of CA PPO |
$1,509.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$862.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$862.58
|
| Rate for Payer: Galaxy Health WC |
$1,832.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1,293.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,438.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$821.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$517.55
|
| Rate for Payer: Multiplan Commercial |
$1,725.17
|
| Rate for Payer: Networks By Design Commercial |
$1,078.23
|
| Rate for Payer: Prime Health Services Commercial |
$1,832.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$814.28
|
| Rate for Payer: United Healthcare All Other HMO |
$795.30
|
| Rate for Payer: United Healthcare HMO Rider |
$778.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$711.63
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE [216968]
|
Facility
|
OP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG216968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$517.55 |
| Max. Negotiated Rate |
$1,832.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,414.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,832.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,186.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,186.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,284.82
|
| Rate for Payer: Blue Distinction Transplant |
$1,293.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1,589.31
|
| Rate for Payer: Blue Shield of California EPN |
$1,259.37
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cigna of CA HMO |
$1,509.52
|
| Rate for Payer: Cigna of CA PPO |
$1,509.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,832.99
|
| Rate for Payer: Dignity Health Media |
$1,832.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,832.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$862.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$862.58
|
| Rate for Payer: Galaxy Health WC |
$1,832.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1,293.88
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,617.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,438.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$821.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$517.55
|
| Rate for Payer: Multiplan Commercial |
$1,725.17
|
| Rate for Payer: Networks By Design Commercial |
$1,078.23
|
| Rate for Payer: Prime Health Services Commercial |
$1,832.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,293.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,293.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,078.23
|
| Rate for Payer: United Healthcare All Other HMO |
$1,078.23
|
| Rate for Payer: United Healthcare HMO Rider |
$1,078.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,078.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,832.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,832.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1,832.99
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE [216968]
|
Facility
|
IP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG216968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$517.55 |
| Max. Negotiated Rate |
$1,832.99 |
| Rate for Payer: Blue Shield of California Commercial |
$1,535.40
|
| Rate for Payer: Blue Shield of California EPN |
$1,104.11
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cigna of CA HMO |
$1,509.52
|
| Rate for Payer: Cigna of CA PPO |
$1,509.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$862.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$862.58
|
| Rate for Payer: Galaxy Health WC |
$1,832.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1,293.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,438.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$821.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$517.55
|
| Rate for Payer: Multiplan Commercial |
$1,725.17
|
| Rate for Payer: Networks By Design Commercial |
$1,078.23
|
| Rate for Payer: Prime Health Services Commercial |
$1,832.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$814.28
|
| Rate for Payer: United Healthcare All Other HMO |
$795.30
|
| Rate for Payer: United Healthcare HMO Rider |
$778.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$711.63
|
|
|
SCHIZOPHRENIA
|
Facility
|
IP
|
$10,355.23
|
|
|
Service Code
|
APR-DRG 7502
|
| Min. Negotiated Rate |
$7,943.55 |
| Max. Negotiated Rate |
$10,355.23 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,943.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,355.23
|
|
|
SCHIZOPHRENIA
|
Facility
|
IP
|
$39,198.79
|
|
|
Service Code
|
APR-DRG 7504
|
| Min. Negotiated Rate |
$30,069.60 |
| Max. Negotiated Rate |
$39,198.79 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30,069.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39,198.79
|
|
|
SCHIZOPHRENIA
|
Facility
|
IP
|
$8,308.66
|
|
|
Service Code
|
APR-DRG 7501
|
| Min. Negotiated Rate |
$6,373.62 |
| Max. Negotiated Rate |
$8,308.66 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,373.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,308.66
|
|
|
SCHIZOPHRENIA
|
Facility
|
IP
|
$17,333.80
|
|
|
Service Code
|
APR-DRG 7503
|
| Min. Negotiated Rate |
$13,296.85 |
| Max. Negotiated Rate |
$17,333.80 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,296.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,333.80
|
|
|
Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluoroscopy) and radiological supervision and interpretation when performed
|
Facility
|
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 49185
|
| Min. Negotiated Rate |
$1,749.33 |
| Max. Negotiated Rate |
$7,385.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7,385.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,025.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,984.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Dignity Health Media |
$2,025.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,228.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,734.68
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,025.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,025.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,322.13
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,322.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,281.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3,281.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,025.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,749.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,025.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,552.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,714.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$19.26
|
|
|
Service Code
|
NDC 45802-580-84
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$16.37 |
| Rate for Payer: Blue Shield of California Commercial |
$13.71
|
| Rate for Payer: Blue Shield of California EPN |
$9.86
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cigna of CA HMO |
$13.48
|
| Rate for Payer: Cigna of CA PPO |
$13.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.70
|
| Rate for Payer: Galaxy Health WC |
$16.37
|
| Rate for Payer: Global Benefits Group Commercial |
$11.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: Multiplan Commercial |
$15.41
|
| Rate for Payer: Networks By Design Commercial |
$12.52
|
| Rate for Payer: Prime Health Services Commercial |
$16.37
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-97
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.14
|
| Rate for Payer: Blue Distinction Transplant |
$13.24
|
| Rate for Payer: Blue Shield of California Commercial |
$16.26
|
| Rate for Payer: Blue Shield of California EPN |
$12.88
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cigna of CA HMO |
$15.44
|
| Rate for Payer: Cigna of CA PPO |
$15.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.75
|
| Rate for Payer: Dignity Health Media |
$18.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.82
|
| Rate for Payer: Galaxy Health WC |
$18.75
|
| Rate for Payer: Global Benefits Group Commercial |
$13.24
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$16.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.29
|
| Rate for Payer: Multiplan Commercial |
$17.65
|
| Rate for Payer: Networks By Design Commercial |
$14.34
|
| Rate for Payer: Prime Health Services Commercial |
$18.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.03
|
| Rate for Payer: United Healthcare All Other HMO |
$11.03
|
| Rate for Payer: United Healthcare HMO Rider |
$11.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.75
|
| Rate for Payer: Vantage Medical Group Senior |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$19.39
|
|
|
Service Code
|
NDC 0378-6470-99
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$16.48 |
| Rate for Payer: Blue Shield of California Commercial |
$13.81
|
| Rate for Payer: Blue Shield of California EPN |
$9.93
|
| Rate for Payer: Cash Price |
$8.73
|
| Rate for Payer: Cigna of CA HMO |
$13.57
|
| Rate for Payer: Cigna of CA PPO |
$13.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.76
|
| Rate for Payer: Galaxy Health WC |
$16.48
|
| Rate for Payer: Global Benefits Group Commercial |
$11.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.65
|
| Rate for Payer: Multiplan Commercial |
$15.51
|
| Rate for Payer: Networks By Design Commercial |
$12.60
|
| Rate for Payer: Prime Health Services Commercial |
$16.48
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-16
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Blue Shield of California Commercial |
$15.71
|
| Rate for Payer: Blue Shield of California EPN |
$11.29
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cigna of CA HMO |
$15.44
|
| Rate for Payer: Cigna of CA PPO |
$15.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.82
|
| Rate for Payer: Galaxy Health WC |
$18.75
|
| Rate for Payer: Global Benefits Group Commercial |
$13.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.29
|
| Rate for Payer: Multiplan Commercial |
$17.65
|
| Rate for Payer: Networks By Design Commercial |
$14.34
|
| Rate for Payer: Prime Health Services Commercial |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
NDC 45802-580-01
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.52 |
| Max. Negotiated Rate |
$19.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$15.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.70
|
| Rate for Payer: Blue Distinction Transplant |
$13.80
|
| Rate for Payer: Blue Shield of California Commercial |
$16.95
|
| Rate for Payer: Blue Shield of California EPN |
$13.43
|
| Rate for Payer: Cash Price |
$10.35
|
| Rate for Payer: Cigna of CA HMO |
$16.10
|
| Rate for Payer: Cigna of CA PPO |
$16.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.55
|
| Rate for Payer: Dignity Health Media |
$19.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.20
|
| Rate for Payer: Galaxy Health WC |
$19.55
|
| Rate for Payer: Global Benefits Group Commercial |
$13.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$17.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Networks By Design Commercial |
$14.95
|
| Rate for Payer: Prime Health Services Commercial |
$19.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.50
|
| Rate for Payer: United Healthcare All Other HMO |
$11.50
|
| Rate for Payer: United Healthcare HMO Rider |
$11.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.55
|
| Rate for Payer: Vantage Medical Group Senior |
$19.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-97
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Blue Shield of California Commercial |
$15.71
|
| Rate for Payer: Blue Shield of California EPN |
$11.29
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cigna of CA HMO |
$15.44
|
| Rate for Payer: Cigna of CA PPO |
$15.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.82
|
| Rate for Payer: Galaxy Health WC |
$18.75
|
| Rate for Payer: Global Benefits Group Commercial |
$13.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.29
|
| Rate for Payer: Multiplan Commercial |
$17.65
|
| Rate for Payer: Networks By Design Commercial |
$14.34
|
| Rate for Payer: Prime Health Services Commercial |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-16
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.14
|
| Rate for Payer: Blue Distinction Transplant |
$13.24
|
| Rate for Payer: Blue Shield of California Commercial |
$16.26
|
| Rate for Payer: Blue Shield of California EPN |
$12.88
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cigna of CA HMO |
$15.44
|
| Rate for Payer: Cigna of CA PPO |
$15.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.75
|
| Rate for Payer: Dignity Health Media |
$18.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.82
|
| Rate for Payer: Galaxy Health WC |
$18.75
|
| Rate for Payer: Global Benefits Group Commercial |
$13.24
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$16.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.29
|
| Rate for Payer: Multiplan Commercial |
$17.65
|
| Rate for Payer: Networks By Design Commercial |
$14.34
|
| Rate for Payer: Prime Health Services Commercial |
$18.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.03
|
| Rate for Payer: United Healthcare All Other HMO |
$11.03
|
| Rate for Payer: United Healthcare HMO Rider |
$11.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.75
|
| Rate for Payer: Vantage Medical Group Senior |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$19.26
|
|
|
Service Code
|
NDC 45802-580-84
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$16.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.48
|
| Rate for Payer: Blue Distinction Transplant |
$11.56
|
| Rate for Payer: Blue Shield of California Commercial |
$14.19
|
| Rate for Payer: Blue Shield of California EPN |
$11.25
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cigna of CA HMO |
$13.48
|
| Rate for Payer: Cigna of CA PPO |
$13.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.37
|
| Rate for Payer: Dignity Health Media |
$16.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.70
|
| Rate for Payer: Galaxy Health WC |
$16.37
|
| Rate for Payer: Global Benefits Group Commercial |
$11.56
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$14.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: Multiplan Commercial |
$15.41
|
| Rate for Payer: Networks By Design Commercial |
$12.52
|
| Rate for Payer: Prime Health Services Commercial |
$16.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.63
|
| Rate for Payer: United Healthcare All Other HMO |
$9.63
|
| Rate for Payer: United Healthcare HMO Rider |
$9.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.37
|
| Rate for Payer: Vantage Medical Group Senior |
$16.37
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
NDC 45802-580-01
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.52 |
| Max. Negotiated Rate |
$19.55 |
| Rate for Payer: Blue Shield of California Commercial |
$16.38
|
| Rate for Payer: Blue Shield of California EPN |
$11.78
|
| Rate for Payer: Cash Price |
$10.35
|
| Rate for Payer: Cigna of CA HMO |
$16.10
|
| Rate for Payer: Cigna of CA PPO |
$16.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.20
|
| Rate for Payer: Galaxy Health WC |
$19.55
|
| Rate for Payer: Global Benefits Group Commercial |
$13.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Networks By Design Commercial |
$14.95
|
| Rate for Payer: Prime Health Services Commercial |
$19.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$19.39
|
|
|
Service Code
|
NDC 0378-6470-99
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$16.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.55
|
| Rate for Payer: Blue Distinction Transplant |
$11.63
|
| Rate for Payer: Blue Shield of California Commercial |
$14.29
|
| Rate for Payer: Blue Shield of California EPN |
$11.32
|
| Rate for Payer: Cash Price |
$8.73
|
| Rate for Payer: Cigna of CA HMO |
$13.57
|
| Rate for Payer: Cigna of CA PPO |
$13.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.48
|
| Rate for Payer: Dignity Health Media |
$16.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.76
|
| Rate for Payer: Galaxy Health WC |
$16.48
|
| Rate for Payer: Global Benefits Group Commercial |
$11.63
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$14.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.65
|
| Rate for Payer: Multiplan Commercial |
$15.51
|
| Rate for Payer: Networks By Design Commercial |
$12.60
|
| Rate for Payer: Prime Health Services Commercial |
$16.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.70
|
| Rate for Payer: United Healthcare All Other HMO |
$9.70
|
| Rate for Payer: United Healthcare HMO Rider |
$9.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.48
|
| Rate for Payer: Vantage Medical Group Senior |
$16.48
|
|
