|
SIGNS AND SYMPTOMS WITH MCC
|
Facility
|
IP
|
$33,409.34
|
|
|
Service Code
|
MSDRG 947
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$33,409.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$33,409.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$21,581.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30,214.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$30,375.21
|
| Rate for Payer: EPIC Health Plan Senior |
$20,250.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18,409.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$25,772.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24,668.35
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$18,409.22
|
| Rate for Payer: Prime Health Services Medicare |
$19,513.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
SIGNS AND SYMPTOMS WITHOUT MCC
|
Facility
|
IP
|
$21,068.36
|
|
|
Service Code
|
MSDRG 948
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$21,068.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$21,068.36
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13,609.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19,053.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$19,704.53
|
| Rate for Payer: EPIC Health Plan Senior |
$13,136.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11,942.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16,719.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16,002.47
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$11,942.14
|
| Rate for Payer: Prime Health Services Medicare |
$12,658.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
|
IP
|
$23,533.80
|
|
|
Service Code
|
APR-DRG 8614
|
| Min. Negotiated Rate |
$14,863.45 |
| Max. Negotiated Rate |
$23,533.80 |
| Rate for Payer: Adventist Health Medi-Cal |
$14,863.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$17,712.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23,533.80
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
|
IP
|
$6,791.85
|
|
|
Service Code
|
APR-DRG 8611
|
| Min. Negotiated Rate |
$4,289.59 |
| Max. Negotiated Rate |
$6,791.85 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,289.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$5,111.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6,791.85
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
|
IP
|
$14,550.50
|
|
|
Service Code
|
APR-DRG 8613
|
| Min. Negotiated Rate |
$9,189.79 |
| Max. Negotiated Rate |
$14,550.50 |
| Rate for Payer: Adventist Health Medi-Cal |
$9,189.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$10,951.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14,550.50
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
|
IP
|
$10,105.19
|
|
|
Service Code
|
APR-DRG 8612
|
| Min. Negotiated Rate |
$6,382.22 |
| Max. Negotiated Rate |
$10,105.19 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,382.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7,605.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10,105.19
|
|
|
SILDENAFIL 10 MG/12.5 ML INTRAVENOUS SOLUTION [100417]
|
Facility
|
OP
|
$26.07
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.21 |
| Max. Negotiated Rate |
$23.46 |
| Rate for Payer: Adventist Health Commercial |
$5.21
|
| Rate for Payer: Adventist Health Commercial |
$3.55
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$15.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.55
|
| Rate for Payer: Blue Shield of California Commercial |
$16.53
|
| Rate for Payer: Blue Shield of California Commercial |
$11.26
|
| Rate for Payer: Blue Shield of California EPN |
$10.40
|
| Rate for Payer: Blue Shield of California EPN |
$7.09
|
| Rate for Payer: Cash Price |
$7.99
|
| Rate for Payer: Cash Price |
$11.73
|
| Rate for Payer: Central Health Plan Commercial |
$14.21
|
| Rate for Payer: Central Health Plan Commercial |
$20.86
|
| Rate for Payer: Cigna of CA HMO |
$18.25
|
| Rate for Payer: Cigna of CA HMO |
$12.43
|
| Rate for Payer: Cigna of CA PPO |
$12.43
|
| Rate for Payer: Cigna of CA PPO |
$18.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$22.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.43
|
| Rate for Payer: EPIC Health Plan Senior |
$10.43
|
| Rate for Payer: EPIC Health Plan Senior |
$7.10
|
| Rate for Payer: Galaxy Health WC |
$15.10
|
| Rate for Payer: Galaxy Health WC |
$22.16
|
| Rate for Payer: Global Benefits Group Commercial |
$10.66
|
| Rate for Payer: Global Benefits Group Commercial |
$15.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$23.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$16.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.43
|
| Rate for Payer: Multiplan Commercial |
$13.32
|
| Rate for Payer: Multiplan Commercial |
$19.55
|
| Rate for Payer: Networks By Design Commercial |
$13.04
|
| Rate for Payer: Networks By Design Commercial |
$8.88
|
| Rate for Payer: Prime Health Services Commercial |
$22.16
|
| Rate for Payer: Prime Health Services Commercial |
$15.10
|
| Rate for Payer: Riverside University Health System MISP |
$10.43
|
| Rate for Payer: Riverside University Health System MISP |
$7.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.78
|
| Rate for Payer: United Healthcare All Other HMO |
$6.49
|
| Rate for Payer: United Healthcare All Other HMO |
$9.52
|
| Rate for Payer: United Healthcare HMO Rider |
$6.35
|
| Rate for Payer: United Healthcare HMO Rider |
$9.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.16
|
| Rate for Payer: Vantage Medical Group Senior |
$15.10
|
| Rate for Payer: Vantage Medical Group Senior |
$22.16
|
|
|
SILDENAFIL 10 MG/12.5 ML INTRAVENOUS SOLUTION [100417]
|
Facility
|
IP
|
$26.07
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.21 |
| Max. Negotiated Rate |
$23.46 |
| Rate for Payer: Adventist Health Commercial |
$5.21
|
| Rate for Payer: Adventist Health Commercial |
$3.55
|
| Rate for Payer: Blue Shield of California Commercial |
$20.91
|
| Rate for Payer: Blue Shield of California Commercial |
$14.24
|
| Rate for Payer: Blue Shield of California EPN |
$8.95
|
| Rate for Payer: Blue Shield of California EPN |
$13.14
|
| Rate for Payer: Cash Price |
$11.73
|
| Rate for Payer: Cash Price |
$7.99
|
| Rate for Payer: Central Health Plan Commercial |
$20.86
|
| Rate for Payer: Central Health Plan Commercial |
$14.21
|
| Rate for Payer: Cigna of CA HMO |
$12.43
|
| Rate for Payer: Cigna of CA HMO |
$18.25
|
| Rate for Payer: Cigna of CA PPO |
$12.43
|
| Rate for Payer: Cigna of CA PPO |
$18.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.43
|
| Rate for Payer: EPIC Health Plan Senior |
$7.10
|
| Rate for Payer: EPIC Health Plan Senior |
$10.43
|
| Rate for Payer: Galaxy Health WC |
$22.16
|
| Rate for Payer: Galaxy Health WC |
$15.10
|
| Rate for Payer: Global Benefits Group Commercial |
$10.66
|
| Rate for Payer: Global Benefits Group Commercial |
$15.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$23.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$16.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.55
|
| Rate for Payer: Multiplan Commercial |
$13.32
|
| Rate for Payer: Multiplan Commercial |
$19.55
|
| Rate for Payer: Networks By Design Commercial |
$8.88
|
| Rate for Payer: Networks By Design Commercial |
$13.04
|
| Rate for Payer: Prime Health Services Commercial |
$22.16
|
| Rate for Payer: Prime Health Services Commercial |
$15.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.78
|
| Rate for Payer: United Healthcare All Other HMO |
$9.52
|
| Rate for Payer: United Healthcare All Other HMO |
$6.49
|
| Rate for Payer: United Healthcare HMO Rider |
$6.35
|
| Rate for Payer: United Healthcare HMO Rider |
$9.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.54
|
|
|
SILDENAFIL 25 MG TABLET [22836]
|
Facility
|
OP
|
$104.91
|
|
|
Service Code
|
NDC 0069420030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.98 |
| Max. Negotiated Rate |
$94.42 |
| Rate for Payer: Adventist Health Commercial |
$20.98
|
| Rate for Payer: Aetna of CA HMO/PPO |
$63.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$57.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$78.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$50.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.03
|
| Rate for Payer: Blue Shield of California Commercial |
$66.51
|
| Rate for Payer: Blue Shield of California EPN |
$41.86
|
| Rate for Payer: Cash Price |
$47.21
|
| Rate for Payer: Central Health Plan Commercial |
$83.93
|
| Rate for Payer: Cigna of CA HMO |
$73.44
|
| Rate for Payer: Cigna of CA PPO |
$73.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$89.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$73.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.96
|
| Rate for Payer: EPIC Health Plan Senior |
$41.96
|
| Rate for Payer: Galaxy Health WC |
$89.17
|
| Rate for Payer: Global Benefits Group Commercial |
$62.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$94.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$66.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$38.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$61.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$73.44
|
| Rate for Payer: Multiplan Commercial |
$78.68
|
| Rate for Payer: Networks By Design Commercial |
$68.19
|
| Rate for Payer: Prime Health Services Commercial |
$89.17
|
| Rate for Payer: Riverside University Health System MISP |
$41.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$62.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$62.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.45
|
| Rate for Payer: United Healthcare All Other HMO |
$52.45
|
| Rate for Payer: United Healthcare HMO Rider |
$52.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.17
|
| Rate for Payer: Vantage Medical Group Senior |
$89.17
|
|
|
SILDENAFIL 25 MG TABLET [22836]
|
Facility
|
IP
|
$104.91
|
|
|
Service Code
|
NDC 0069420030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.98 |
| Max. Negotiated Rate |
$94.42 |
| Rate for Payer: Adventist Health Commercial |
$20.98
|
| Rate for Payer: Blue Shield of California Commercial |
$84.14
|
| Rate for Payer: Blue Shield of California EPN |
$52.87
|
| Rate for Payer: Cash Price |
$47.21
|
| Rate for Payer: Central Health Plan Commercial |
$83.93
|
| Rate for Payer: Cigna of CA HMO |
$73.44
|
| Rate for Payer: Cigna of CA PPO |
$73.44
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$73.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.96
|
| Rate for Payer: EPIC Health Plan Senior |
$41.96
|
| Rate for Payer: Galaxy Health WC |
$89.17
|
| Rate for Payer: Global Benefits Group Commercial |
$62.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$94.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$66.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$61.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.98
|
| Rate for Payer: Multiplan Commercial |
$78.68
|
| Rate for Payer: Networks By Design Commercial |
$68.19
|
| Rate for Payer: Prime Health Services Commercial |
$89.17
|
|
|
SILDENAFIL ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080335]
|
Facility
|
IP
|
$2.81
|
|
|
Service Code
|
NDC 9994080335
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$2.25
|
| Rate for Payer: Blue Shield of California EPN |
$1.42
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Central Health Plan Commercial |
$2.25
|
| Rate for Payer: Cigna of CA HMO |
$1.97
|
| Rate for Payer: Cigna of CA PPO |
$1.97
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: EPIC Health Plan Senior |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.39
|
| Rate for Payer: Global Benefits Group Commercial |
$1.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$2.11
|
| Rate for Payer: Networks By Design Commercial |
$1.83
|
| Rate for Payer: Prime Health Services Commercial |
$2.39
|
|
|
SILDENAFIL ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080335]
|
Facility
|
OP
|
$2.81
|
|
|
Service Code
|
NDC 9994080335
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Central Health Plan Commercial |
$2.25
|
| Rate for Payer: Cigna of CA HMO |
$1.97
|
| Rate for Payer: Cigna of CA PPO |
$1.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: EPIC Health Plan Senior |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.39
|
| Rate for Payer: Global Benefits Group Commercial |
$1.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.97
|
| Rate for Payer: Multiplan Commercial |
$2.11
|
| Rate for Payer: Networks By Design Commercial |
$1.83
|
| Rate for Payer: Prime Health Services Commercial |
$2.39
|
| Rate for Payer: Riverside University Health System MISP |
$1.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.41
|
| Rate for Payer: United Healthcare All Other HMO |
$1.41
|
| Rate for Payer: United Healthcare HMO Rider |
$1.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.39
|
| Rate for Payer: Vantage Medical Group Senior |
$2.39
|
|
|
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]
|
Facility
|
IP
|
$0.89
|
|
|
Service Code
|
HCPCS S0090
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.71
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Central Health Plan Commercial |
$1.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.71
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Senior |
$0.56
|
| Rate for Payer: EPIC Health Plan Senior |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.76
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Prime Health Services Commercial |
$0.76
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
|
|
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
HCPCS S0090
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$64.33 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$51.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$51.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.89
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Central Health Plan Commercial |
$0.71
|
| Rate for Payer: Central Health Plan Commercial |
$1.12
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.98
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Senior |
$0.36
|
| Rate for Payer: EPIC Health Plan Senior |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$0.76
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Networks By Design Commercial |
$0.58
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.76
|
| Rate for Payer: Riverside University Health System MISP |
$0.36
|
| Rate for Payer: Riverside University Health System MISP |
$0.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.70
|
| Rate for Payer: United Healthcare HMO Rider |
$0.70
|
| Rate for Payer: United Healthcare HMO Rider |
$0.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.76
|
|
|
SILTUXIMAB 100 MG INTRAVENOUS SOLUTION [205871]
|
Facility
|
OP
|
$2,019.94
|
|
|
Service Code
|
HCPCS J2860
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$169.84 |
| Max. Negotiated Rate |
$1,817.95 |
| Rate for Payer: Adventist Health Commercial |
$403.99
|
| Rate for Payer: Adventist Health Medi-Cal |
$174.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,012.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$217.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$191.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$191.48
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$169.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$211.94
|
| Rate for Payer: Blue Shield of California Commercial |
$203.54
|
| Rate for Payer: Blue Shield of California EPN |
$185.04
|
| Rate for Payer: Cash Price |
$908.97
|
| Rate for Payer: Cash Price |
$908.97
|
| Rate for Payer: Central Health Plan Commercial |
$1,615.95
|
| Rate for Payer: Cigna of CA HMO |
$1,413.96
|
| Rate for Payer: Cigna of CA PPO |
$1,413.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$217.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$191.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$191.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,413.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$287.22
|
| Rate for Payer: EPIC Health Plan Senior |
$191.48
|
| Rate for Payer: Galaxy Health WC |
$1,716.95
|
| Rate for Payer: Global Benefits Group Commercial |
$1,211.96
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,817.95
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$285.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$174.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$174.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,282.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$320.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$243.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$403.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$233.25
|
| Rate for Payer: Multiplan Commercial |
$1,514.95
|
| Rate for Payer: Networks By Design Commercial |
$1,009.97
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$174.07
|
| Rate for Payer: Prime Health Services Commercial |
$1,716.95
|
| Rate for Payer: Prime Health Services Medicare |
$184.51
|
| Rate for Payer: Riverside University Health System MISP |
$191.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,211.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,211.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$758.08
|
| Rate for Payer: United Healthcare All Other HMO |
$737.88
|
| Rate for Payer: United Healthcare HMO Rider |
$721.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$661.53
|
| Rate for Payer: Upland Medical Group Pediatric |
$174.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$217.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$191.48
|
| Rate for Payer: Vantage Medical Group Senior |
$191.48
|
|
|
SILTUXIMAB 100 MG INTRAVENOUS SOLUTION [205871]
|
Facility
|
IP
|
$2,019.94
|
|
|
Service Code
|
HCPCS J2860
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$403.99 |
| Max. Negotiated Rate |
$1,817.95 |
| Rate for Payer: Adventist Health Commercial |
$403.99
|
| Rate for Payer: Blue Shield of California Commercial |
$1,619.99
|
| Rate for Payer: Blue Shield of California EPN |
$1,018.05
|
| Rate for Payer: Cash Price |
$908.97
|
| Rate for Payer: Central Health Plan Commercial |
$1,615.95
|
| Rate for Payer: Cigna of CA HMO |
$1,413.96
|
| Rate for Payer: Cigna of CA PPO |
$1,413.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,413.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$807.98
|
| Rate for Payer: EPIC Health Plan Senior |
$807.98
|
| Rate for Payer: Galaxy Health WC |
$1,716.95
|
| Rate for Payer: Global Benefits Group Commercial |
$1,211.96
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,817.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,282.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,191.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$403.99
|
| Rate for Payer: Multiplan Commercial |
$1,514.95
|
| Rate for Payer: Networks By Design Commercial |
$1,009.97
|
| Rate for Payer: Prime Health Services Commercial |
$1,716.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$758.08
|
| Rate for Payer: United Healthcare All Other HMO |
$737.88
|
| Rate for Payer: United Healthcare HMO Rider |
$721.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$661.53
|
|
|
SILTUXIMAB 400 MG INTRAVENOUS SOLUTION [205872]
|
Facility
|
IP
|
$8,079.72
|
|
|
Service Code
|
HCPCS J2860
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,615.94 |
| Max. Negotiated Rate |
$7,271.75 |
| Rate for Payer: Adventist Health Commercial |
$1,615.94
|
| Rate for Payer: Blue Shield of California Commercial |
$6,479.94
|
| Rate for Payer: Blue Shield of California EPN |
$4,072.18
|
| Rate for Payer: Cash Price |
$3,635.87
|
| Rate for Payer: Central Health Plan Commercial |
$6,463.78
|
| Rate for Payer: Cigna of CA HMO |
$5,655.80
|
| Rate for Payer: Cigna of CA PPO |
$5,655.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5,655.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,231.89
|
| Rate for Payer: EPIC Health Plan Senior |
$3,231.89
|
| Rate for Payer: Galaxy Health WC |
$6,867.76
|
| Rate for Payer: Global Benefits Group Commercial |
$4,847.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$7,271.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5,130.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,767.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,615.94
|
| Rate for Payer: Multiplan Commercial |
$6,059.79
|
| Rate for Payer: Networks By Design Commercial |
$4,039.86
|
| Rate for Payer: Prime Health Services Commercial |
$6,867.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,032.32
|
| Rate for Payer: United Healthcare All Other HMO |
$2,951.52
|
| Rate for Payer: United Healthcare HMO Rider |
$2,887.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,646.11
|
|
|
SILTUXIMAB 400 MG INTRAVENOUS SOLUTION [205872]
|
Facility
|
OP
|
$8,079.72
|
|
|
Service Code
|
HCPCS J2860
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$169.84 |
| Max. Negotiated Rate |
$7,271.75 |
| Rate for Payer: Adventist Health Commercial |
$1,615.94
|
| Rate for Payer: Adventist Health Medi-Cal |
$174.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,012.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$217.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$191.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$191.48
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$169.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$211.94
|
| Rate for Payer: Blue Shield of California Commercial |
$203.54
|
| Rate for Payer: Blue Shield of California EPN |
$185.04
|
| Rate for Payer: Cash Price |
$3,635.87
|
| Rate for Payer: Cash Price |
$3,635.87
|
| Rate for Payer: Central Health Plan Commercial |
$6,463.78
|
| Rate for Payer: Cigna of CA HMO |
$5,655.80
|
| Rate for Payer: Cigna of CA PPO |
$5,655.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$217.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$191.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$191.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5,655.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$287.22
|
| Rate for Payer: EPIC Health Plan Senior |
$191.48
|
| Rate for Payer: Galaxy Health WC |
$6,867.76
|
| Rate for Payer: Global Benefits Group Commercial |
$4,847.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$7,271.75
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$285.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$174.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$174.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5,130.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$320.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$243.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,615.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$233.25
|
| Rate for Payer: Multiplan Commercial |
$6,059.79
|
| Rate for Payer: Networks By Design Commercial |
$4,039.86
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$174.07
|
| Rate for Payer: Prime Health Services Commercial |
$6,867.76
|
| Rate for Payer: Prime Health Services Medicare |
$184.51
|
| Rate for Payer: Riverside University Health System MISP |
$191.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4,847.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4,847.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,032.32
|
| Rate for Payer: United Healthcare All Other HMO |
$2,951.52
|
| Rate for Payer: United Healthcare HMO Rider |
$2,887.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,646.11
|
| Rate for Payer: Upland Medical Group Pediatric |
$174.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$217.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$191.48
|
| Rate for Payer: Vantage Medical Group Senior |
$191.48
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 8327030909
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Central Health Plan Commercial |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
| Rate for Payer: Riverside University Health System MISP |
$0.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO |
$0.35
|
| Rate for Payer: United Healthcare HMO Rider |
$0.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 8327030909
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Central Health Plan Commercial |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 8019629660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Central Health Plan Commercial |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
| Rate for Payer: Riverside University Health System MISP |
$0.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO |
$0.35
|
| Rate for Payer: United Healthcare HMO Rider |
$0.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 8019629660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Central Health Plan Commercial |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 1287000011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Central Health Plan Commercial |
$0.73
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Senior |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 1287000012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Central Health Plan Commercial |
$0.67
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Senior |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 1287000012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.49
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Central Health Plan Commercial |
$0.67
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.71
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Senior |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Riverside University Health System MISP |
$0.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
