|
SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]
|
Facility
|
OP
|
$630.00
|
|
|
Service Code
|
CPT J2850
|
| Hospital Charge Code |
ERX91185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.38 |
| Max. Negotiated Rate |
$535.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$203.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$45.18
|
| Rate for Payer: Blue Distinction Transplant |
$378.00
|
| Rate for Payer: Blue Shield of California Commercial |
$464.31
|
| Rate for Payer: Blue Shield of California EPN |
$39.38
|
| Rate for Payer: Cash Price |
$283.50
|
| Rate for Payer: Cash Price |
$283.50
|
| Rate for Payer: Cigna of CA HMO |
$441.00
|
| Rate for Payer: Cigna of CA PPO |
$441.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62.61
|
| Rate for Payer: Dignity Health Media |
$41.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.35
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$41.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.74
|
| Rate for Payer: Galaxy Health WC |
$535.50
|
| Rate for Payer: Global Benefits Group Commercial |
$378.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$472.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$68.45
|
| Rate for Payer: Heritage Provider Network Transplant |
$68.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$67.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$67.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$41.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$420.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$70.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$41.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$52.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$55.93
|
| Rate for Payer: Multiplan Commercial |
$504.00
|
| Rate for Payer: Networks By Design Commercial |
$315.00
|
| Rate for Payer: Prime Health Services Commercial |
$535.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$378.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$378.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$315.00
|
| Rate for Payer: United Healthcare All Other HMO |
$315.00
|
| Rate for Payer: United Healthcare HMO Rider |
$315.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$315.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$62.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.91
|
| Rate for Payer: Vantage Medical Group Senior |
$41.74
|
|
|
SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]
|
Facility
|
IP
|
$630.00
|
|
|
Service Code
|
CPT J2850
|
| Hospital Charge Code |
ERX91185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$151.20 |
| Max. Negotiated Rate |
$535.50 |
| Rate for Payer: Blue Shield of California Commercial |
$448.56
|
| Rate for Payer: Blue Shield of California EPN |
$322.56
|
| Rate for Payer: Cash Price |
$283.50
|
| Rate for Payer: Cigna of CA HMO |
$441.00
|
| Rate for Payer: Cigna of CA PPO |
$441.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$252.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$252.00
|
| Rate for Payer: Galaxy Health WC |
$535.50
|
| Rate for Payer: Global Benefits Group Commercial |
$378.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$420.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$240.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.20
|
| Rate for Payer: Multiplan Commercial |
$504.00
|
| Rate for Payer: Networks By Design Commercial |
$315.00
|
| Rate for Payer: Prime Health Services Commercial |
$535.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$237.89
|
| Rate for Payer: United Healthcare All Other HMO |
$232.34
|
| Rate for Payer: United Healthcare HMO Rider |
$227.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$207.90
|
|
|
SEIZURE
|
Facility
|
IP
|
$28,848.88
|
|
|
Service Code
|
APR-DRG 0534
|
| Min. Negotiated Rate |
$22,130.13 |
| Max. Negotiated Rate |
$28,848.88 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22,130.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28,848.88
|
|
|
SEIZURE
|
Facility
|
IP
|
$7,629.43
|
|
|
Service Code
|
APR-DRG 0531
|
| Min. Negotiated Rate |
$5,852.58 |
| Max. Negotiated Rate |
$7,629.43 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,852.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7,629.43
|
|
|
SEIZURE
|
Facility
|
IP
|
$9,730.98
|
|
|
Service Code
|
APR-DRG 0532
|
| Min. Negotiated Rate |
$7,464.69 |
| Max. Negotiated Rate |
$9,730.98 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,464.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,730.98
|
|
|
SEIZURE
|
Facility
|
IP
|
$12,678.47
|
|
|
Service Code
|
APR-DRG 0533
|
| Min. Negotiated Rate |
$9,725.72 |
| Max. Negotiated Rate |
$12,678.47 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,725.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,678.47
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 60505-0055-1
|
| Hospital Charge Code |
1712623
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.20
|
| Rate for Payer: Blue Distinction Transplant |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO |
$1.41
|
| Rate for Payer: Cigna of CA PPO |
$1.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.71
|
| Rate for Payer: Dignity Health Media |
$1.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.71
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.61
|
| Rate for Payer: Networks By Design Commercial |
$1.31
|
| Rate for Payer: Prime Health Services Commercial |
$1.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1.71
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 60505-0055-1
|
| Hospital Charge Code |
1712623
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Blue Shield of California Commercial |
$1.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO |
$1.41
|
| Rate for Payer: Cigna of CA PPO |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.71
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.61
|
| Rate for Payer: Networks By Design Commercial |
$1.31
|
| Rate for Payer: Prime Health Services Commercial |
$1.71
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 7985401163
|
| Hospital Charge Code |
ERX7139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Distinction Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Media |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 7985401163
|
| Hospital Charge Code |
ERX7139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
SELENIUM 50 MCG TABLET [7140]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 26899-721-74
|
| Hospital Charge Code |
1710887
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
SELENIUM 50 MCG TABLET [7140]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 26899-721-74
|
| Hospital Charge Code |
1710887
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Distinction Transplant |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Media |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]
|
Facility
|
IP
|
$41.16
|
|
|
Service Code
|
NDC 0517-6560-25
|
| Hospital Charge Code |
NDG225026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.88 |
| Max. Negotiated Rate |
$34.99 |
| Rate for Payer: Blue Shield of California Commercial |
$29.31
|
| Rate for Payer: Blue Shield of California EPN |
$21.07
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.46
|
| Rate for Payer: Galaxy Health WC |
$34.99
|
| Rate for Payer: Global Benefits Group Commercial |
$24.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$27.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.88
|
| Rate for Payer: Multiplan Commercial |
$32.93
|
| Rate for Payer: Networks By Design Commercial |
$26.75
|
| Rate for Payer: Prime Health Services Commercial |
$34.99
|
|
|
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]
|
Facility
|
OP
|
$41.16
|
|
|
Service Code
|
NDC 0517-6560-25
|
| Hospital Charge Code |
NDG225026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.88 |
| Max. Negotiated Rate |
$34.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$34.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.52
|
| Rate for Payer: Blue Distinction Transplant |
$24.70
|
| Rate for Payer: Blue Shield of California Commercial |
$30.33
|
| Rate for Payer: Blue Shield of California EPN |
$24.04
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: Cigna of CA HMO |
$26.34
|
| Rate for Payer: Cigna of CA PPO |
$30.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$34.99
|
| Rate for Payer: Dignity Health Media |
$34.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$16.46
|
| Rate for Payer: Galaxy Health WC |
$34.99
|
| Rate for Payer: Global Benefits Group Commercial |
$24.70
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$30.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$27.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.88
|
| Rate for Payer: Multiplan Commercial |
$32.93
|
| Rate for Payer: Networks By Design Commercial |
$26.75
|
| Rate for Payer: Prime Health Services Commercial |
$34.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$24.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$24.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$20.58
|
| Rate for Payer: United Healthcare All Other HMO |
$20.58
|
| Rate for Payer: United Healthcare HMO Rider |
$20.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$20.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$34.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.99
|
| Rate for Payer: Vantage Medical Group Senior |
$34.99
|
|
|
SELENIUM SULFIDE 1 % SHAMPOO [38961]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0536-1995-53
|
| Hospital Charge Code |
1743730
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
SELENIUM SULFIDE 1 % SHAMPOO [38961]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0536-1995-53
|
| Hospital Charge Code |
1743730
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Media |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
SELENIUM SULFIDE 2.25 % SHAMPOO [40158]
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 42192-152-06
|
| Hospital Charge Code |
NDG40158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.53
|
| Rate for Payer: Cigna of CA PPO |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Galaxy Health WC |
$0.64
|
| Rate for Payer: Global Benefits Group Commercial |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.49
|
| Rate for Payer: Prime Health Services Commercial |
$0.64
|
|
|
SELENIUM SULFIDE 2.25 % SHAMPOO [40158]
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 42192-152-06
|
| Hospital Charge Code |
NDG40158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.45
|
| Rate for Payer: Blue Distinction Transplant |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.53
|
| Rate for Payer: Cigna of CA PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.64
|
| Rate for Payer: Dignity Health Media |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.30
|
| Rate for Payer: Galaxy Health WC |
$0.64
|
| Rate for Payer: Global Benefits Group Commercial |
$0.45
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.49
|
| Rate for Payer: Prime Health Services Commercial |
$0.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.38
|
| Rate for Payer: United Healthcare All Other HMO |
$0.38
|
| Rate for Payer: United Healthcare HMO Rider |
$0.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
|
|
SELEXIPAG 200 MCG TABLET [212415]
|
Facility
|
OP
|
$271.97
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
ERX212415
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.27 |
| Max. Negotiated Rate |
$231.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$178.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$231.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$149.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$149.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$162.04
|
| Rate for Payer: Blue Distinction Transplant |
$163.18
|
| Rate for Payer: Blue Shield of California Commercial |
$200.44
|
| Rate for Payer: Blue Shield of California EPN |
$158.83
|
| Rate for Payer: Cash Price |
$122.39
|
| Rate for Payer: Cigna of CA HMO |
$190.38
|
| Rate for Payer: Cigna of CA PPO |
$190.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$231.17
|
| Rate for Payer: Dignity Health Media |
$231.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$231.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$108.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$108.79
|
| Rate for Payer: Galaxy Health WC |
$231.17
|
| Rate for Payer: Global Benefits Group Commercial |
$163.18
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$203.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$181.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$103.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.27
|
| Rate for Payer: Multiplan Commercial |
$217.58
|
| Rate for Payer: Networks By Design Commercial |
$176.78
|
| Rate for Payer: Prime Health Services Commercial |
$231.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$163.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$163.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$135.98
|
| Rate for Payer: United Healthcare All Other HMO |
$135.98
|
| Rate for Payer: United Healthcare HMO Rider |
$135.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$135.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$231.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.17
|
| Rate for Payer: Vantage Medical Group Senior |
$231.17
|
|
|
SELEXIPAG 200 MCG TABLET [212415]
|
Facility
|
IP
|
$271.97
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
ERX212415
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.27 |
| Max. Negotiated Rate |
$231.17 |
| Rate for Payer: Blue Shield of California Commercial |
$193.64
|
| Rate for Payer: Blue Shield of California EPN |
$139.25
|
| Rate for Payer: Cash Price |
$122.39
|
| Rate for Payer: Cigna of CA HMO |
$190.38
|
| Rate for Payer: Cigna of CA PPO |
$190.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$108.79
|
| Rate for Payer: Galaxy Health WC |
$231.17
|
| Rate for Payer: Global Benefits Group Commercial |
$163.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$181.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$103.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.27
|
| Rate for Payer: Multiplan Commercial |
$217.58
|
| Rate for Payer: Networks By Design Commercial |
$176.78
|
| Rate for Payer: Prime Health Services Commercial |
$231.17
|
|
|
SELEXIPAG 400 MCG TABLET [212416]
|
Facility
|
OP
|
$422.95
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
ERX212416
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$101.51 |
| Max. Negotiated Rate |
$359.51 |
| Rate for Payer: Aetna of CA HMO/PPO |
$277.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$359.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$232.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$232.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$251.99
|
| Rate for Payer: Blue Distinction Transplant |
$253.77
|
| Rate for Payer: Blue Shield of California Commercial |
$311.71
|
| Rate for Payer: Blue Shield of California EPN |
$247.00
|
| Rate for Payer: Cash Price |
$190.33
|
| Rate for Payer: Cigna of CA HMO |
$296.06
|
| Rate for Payer: Cigna of CA PPO |
$296.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$359.51
|
| Rate for Payer: Dignity Health Media |
$359.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$359.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$169.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$169.18
|
| Rate for Payer: Galaxy Health WC |
$359.51
|
| Rate for Payer: Global Benefits Group Commercial |
$253.77
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$317.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$282.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$161.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$101.51
|
| Rate for Payer: Multiplan Commercial |
$338.36
|
| Rate for Payer: Networks By Design Commercial |
$274.92
|
| Rate for Payer: Prime Health Services Commercial |
$359.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$253.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$253.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$211.48
|
| Rate for Payer: United Healthcare All Other HMO |
$211.48
|
| Rate for Payer: United Healthcare HMO Rider |
$211.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$211.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$359.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$359.51
|
| Rate for Payer: Vantage Medical Group Senior |
$359.51
|
|
|
SELEXIPAG 400 MCG TABLET [212416]
|
Facility
|
IP
|
$422.95
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
ERX212416
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$101.51 |
| Max. Negotiated Rate |
$359.51 |
| Rate for Payer: Blue Shield of California Commercial |
$301.14
|
| Rate for Payer: Blue Shield of California EPN |
$216.55
|
| Rate for Payer: Cash Price |
$190.33
|
| Rate for Payer: Cigna of CA HMO |
$296.06
|
| Rate for Payer: Cigna of CA PPO |
$296.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$169.18
|
| Rate for Payer: Galaxy Health WC |
$359.51
|
| Rate for Payer: Global Benefits Group Commercial |
$253.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$282.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$161.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$101.51
|
| Rate for Payer: Multiplan Commercial |
$338.36
|
| Rate for Payer: Networks By Design Commercial |
$274.92
|
| Rate for Payer: Prime Health Services Commercial |
$359.51
|
|
|
SELPERCATINIB 40 MG CAPSULE [228076]
|
Facility
|
IP
|
$141.46
|
|
|
Service Code
|
NDC 0002-3977-60
|
| Hospital Charge Code |
ERX228076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.95 |
| Max. Negotiated Rate |
$120.24 |
| Rate for Payer: Blue Shield of California Commercial |
$100.72
|
| Rate for Payer: Blue Shield of California EPN |
$72.43
|
| Rate for Payer: Cash Price |
$63.66
|
| Rate for Payer: Cigna of CA HMO |
$99.02
|
| Rate for Payer: Cigna of CA PPO |
$99.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.58
|
| Rate for Payer: Galaxy Health WC |
$120.24
|
| Rate for Payer: Global Benefits Group Commercial |
$84.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$94.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.95
|
| Rate for Payer: Multiplan Commercial |
$113.17
|
| Rate for Payer: Networks By Design Commercial |
$91.95
|
| Rate for Payer: Prime Health Services Commercial |
$120.24
|
|
|
SELPERCATINIB 40 MG CAPSULE [228076]
|
Facility
|
OP
|
$141.46
|
|
|
Service Code
|
NDC 0002-3977-60
|
| Hospital Charge Code |
ERX228076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.95 |
| Max. Negotiated Rate |
$120.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$92.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$120.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$77.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$77.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$84.28
|
| Rate for Payer: Blue Distinction Transplant |
$84.88
|
| Rate for Payer: Blue Shield of California Commercial |
$104.26
|
| Rate for Payer: Blue Shield of California EPN |
$82.61
|
| Rate for Payer: Cash Price |
$63.66
|
| Rate for Payer: Cigna of CA HMO |
$99.02
|
| Rate for Payer: Cigna of CA PPO |
$99.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$120.24
|
| Rate for Payer: Dignity Health Media |
$120.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$120.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$56.58
|
| Rate for Payer: Galaxy Health WC |
$120.24
|
| Rate for Payer: Global Benefits Group Commercial |
$84.88
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$106.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$94.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.95
|
| Rate for Payer: Multiplan Commercial |
$113.17
|
| Rate for Payer: Networks By Design Commercial |
$91.95
|
| Rate for Payer: Prime Health Services Commercial |
$120.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$84.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$84.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$70.73
|
| Rate for Payer: United Healthcare All Other HMO |
$70.73
|
| Rate for Payer: United Healthcare HMO Rider |
$70.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$70.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$120.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$120.24
|
| Rate for Payer: Vantage Medical Group Senior |
$120.24
|
|
|
SELPERCATINIB 80 MG CAPSULE [228077]
|
Facility
|
IP
|
$212.18
|
|
|
Service Code
|
NDC 0002-2980-60
|
| Hospital Charge Code |
ERX228077
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.92 |
| Max. Negotiated Rate |
$180.35 |
| Rate for Payer: Blue Shield of California Commercial |
$151.07
|
| Rate for Payer: Blue Shield of California EPN |
$108.64
|
| Rate for Payer: Cash Price |
$95.48
|
| Rate for Payer: Cigna of CA HMO |
$148.53
|
| Rate for Payer: Cigna of CA PPO |
$148.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.87
|
| Rate for Payer: Galaxy Health WC |
$180.35
|
| Rate for Payer: Global Benefits Group Commercial |
$127.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.92
|
| Rate for Payer: Multiplan Commercial |
$169.74
|
| Rate for Payer: Networks By Design Commercial |
$137.92
|
| Rate for Payer: Prime Health Services Commercial |
$180.35
|
|
