|
RUXOLITINIB 25 MG TABLET [153890]
|
Facility
|
IP
|
$352.00
|
|
|
Service Code
|
NDC 50881-025-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$316.80 |
| Rate for Payer: Adventist Health Commercial |
$70.40
|
| Rate for Payer: Blue Shield of California Commercial |
$272.10
|
| Rate for Payer: Blue Shield of California EPN |
$177.41
|
| Rate for Payer: Cash Price |
$193.60
|
| Rate for Payer: Central Health Plan Commercial |
$281.60
|
| Rate for Payer: Cigna of CA HMO |
$246.40
|
| Rate for Payer: Cigna of CA PPO |
$246.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.80
|
| Rate for Payer: EPIC Health Plan Senior |
$140.80
|
| Rate for Payer: Galaxy Health WC |
$299.20
|
| Rate for Payer: Global Benefits Group Commercial |
$211.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$316.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$234.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$134.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$217.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.40
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: Networks By Design Commercial |
$228.80
|
| Rate for Payer: Prime Health Services Commercial |
$299.20
|
|
|
RUXOLITINIB 25 MG TABLET [153890]
|
Facility
|
OP
|
$352.00
|
|
|
Service Code
|
NDC 50881-025-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$316.80 |
| Rate for Payer: Adventist Health Commercial |
$70.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$213.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$299.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$193.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$264.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$170.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$206.73
|
| Rate for Payer: Blue Shield of California Commercial |
$215.07
|
| Rate for Payer: Blue Shield of California EPN |
$140.45
|
| Rate for Payer: Cash Price |
$193.60
|
| Rate for Payer: Central Health Plan Commercial |
$281.60
|
| Rate for Payer: Cigna of CA HMO |
$246.40
|
| Rate for Payer: Cigna of CA PPO |
$246.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$299.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$299.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$299.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.80
|
| Rate for Payer: EPIC Health Plan Senior |
$140.80
|
| Rate for Payer: Galaxy Health WC |
$299.20
|
| Rate for Payer: Global Benefits Group Commercial |
$211.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$316.80
|
| Rate for Payer: InnovAge PACE Commercial |
$176.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$234.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$134.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$217.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$246.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$246.40
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: Networks By Design Commercial |
$228.80
|
| Rate for Payer: Prime Health Services Commercial |
$299.20
|
| Rate for Payer: Riverside University Health System MISP |
$140.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$211.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$211.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$176.00
|
| Rate for Payer: United Healthcare All Other HMO |
$176.00
|
| Rate for Payer: United Healthcare HMO Rider |
$176.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$176.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$299.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$299.20
|
| Rate for Payer: Vantage Medical Group Senior |
$299.20
|
|
|
RUXOLITINIB 5 MG TABLET [153886]
|
Facility
|
IP
|
$352.00
|
|
|
Service Code
|
NDC 50881-005-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$316.80 |
| Rate for Payer: Adventist Health Commercial |
$70.40
|
| Rate for Payer: Blue Shield of California Commercial |
$272.10
|
| Rate for Payer: Blue Shield of California EPN |
$177.41
|
| Rate for Payer: Cash Price |
$193.60
|
| Rate for Payer: Central Health Plan Commercial |
$281.60
|
| Rate for Payer: Cigna of CA HMO |
$246.40
|
| Rate for Payer: Cigna of CA PPO |
$246.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.80
|
| Rate for Payer: EPIC Health Plan Senior |
$140.80
|
| Rate for Payer: Galaxy Health WC |
$299.20
|
| Rate for Payer: Global Benefits Group Commercial |
$211.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$316.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$234.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$134.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$217.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.40
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: Networks By Design Commercial |
$228.80
|
| Rate for Payer: Prime Health Services Commercial |
$299.20
|
|
|
RUXOLITINIB 5 MG TABLET [153886]
|
Facility
|
OP
|
$352.00
|
|
|
Service Code
|
NDC 50881-005-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$316.80 |
| Rate for Payer: Adventist Health Commercial |
$70.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$213.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$299.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$193.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$264.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$170.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$206.73
|
| Rate for Payer: Blue Shield of California Commercial |
$215.07
|
| Rate for Payer: Blue Shield of California EPN |
$140.45
|
| Rate for Payer: Cash Price |
$193.60
|
| Rate for Payer: Central Health Plan Commercial |
$281.60
|
| Rate for Payer: Cigna of CA HMO |
$246.40
|
| Rate for Payer: Cigna of CA PPO |
$246.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$299.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$299.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$299.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.80
|
| Rate for Payer: EPIC Health Plan Senior |
$140.80
|
| Rate for Payer: Galaxy Health WC |
$299.20
|
| Rate for Payer: Global Benefits Group Commercial |
$211.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$316.80
|
| Rate for Payer: InnovAge PACE Commercial |
$176.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$234.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$134.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$217.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$246.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$246.40
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: Networks By Design Commercial |
$228.80
|
| Rate for Payer: Prime Health Services Commercial |
$299.20
|
| Rate for Payer: Riverside University Health System MISP |
$140.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$211.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$211.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$176.00
|
| Rate for Payer: United Healthcare All Other HMO |
$176.00
|
| Rate for Payer: United Healthcare HMO Rider |
$176.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$176.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$299.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$299.20
|
| Rate for Payer: Vantage Medical Group Senior |
$299.20
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 62332-556-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Central Health Plan Commercial |
$1.31
|
| Rate for Payer: Cigna of CA HMO |
$1.15
|
| Rate for Payer: Cigna of CA PPO |
$1.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: EPIC Health Plan Senior |
$0.66
|
| Rate for Payer: Galaxy Health WC |
$1.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.48
|
| Rate for Payer: InnovAge PACE Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: Networks By Design Commercial |
$1.07
|
| Rate for Payer: Prime Health Services Commercial |
$1.39
|
| Rate for Payer: Riverside University Health System MISP |
$0.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO |
$0.82
|
| Rate for Payer: United Healthcare HMO Rider |
$0.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Vantage Medical Group Senior |
$1.39
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 62332-556-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$1.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.83
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Central Health Plan Commercial |
$1.31
|
| Rate for Payer: Cigna of CA HMO |
$1.15
|
| Rate for Payer: Cigna of CA PPO |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: EPIC Health Plan Senior |
$0.66
|
| Rate for Payer: Galaxy Health WC |
$1.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: Networks By Design Commercial |
$1.07
|
| Rate for Payer: Prime Health Services Commercial |
$1.39
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
OP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0659-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$12.69 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.57
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.28
|
| Rate for Payer: Blue Shield of California Commercial |
$8.62
|
| Rate for Payer: Blue Shield of California EPN |
$5.63
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Central Health Plan Commercial |
$11.28
|
| Rate for Payer: Cigna of CA HMO |
$9.87
|
| Rate for Payer: Cigna of CA PPO |
$9.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.64
|
| Rate for Payer: EPIC Health Plan Senior |
$5.64
|
| Rate for Payer: Galaxy Health WC |
$11.98
|
| Rate for Payer: Global Benefits Group Commercial |
$8.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.69
|
| Rate for Payer: InnovAge PACE Commercial |
$7.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.87
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
| Rate for Payer: Networks By Design Commercial |
$9.16
|
| Rate for Payer: Prime Health Services Commercial |
$11.98
|
| Rate for Payer: Riverside University Health System MISP |
$5.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.05
|
| Rate for Payer: United Healthcare All Other HMO |
$7.05
|
| Rate for Payer: United Healthcare HMO Rider |
$7.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.98
|
| Rate for Payer: Vantage Medical Group Senior |
$11.98
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
IP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0659-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$12.69 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Blue Shield of California Commercial |
$10.90
|
| Rate for Payer: Blue Shield of California EPN |
$7.11
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Central Health Plan Commercial |
$11.28
|
| Rate for Payer: Cigna of CA HMO |
$9.87
|
| Rate for Payer: Cigna of CA PPO |
$9.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.64
|
| Rate for Payer: EPIC Health Plan Senior |
$5.64
|
| Rate for Payer: Galaxy Health WC |
$11.98
|
| Rate for Payer: Global Benefits Group Commercial |
$8.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
| Rate for Payer: Networks By Design Commercial |
$9.16
|
| Rate for Payer: Prime Health Services Commercial |
$11.98
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
OP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0777-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$12.69 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.57
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.28
|
| Rate for Payer: Blue Shield of California Commercial |
$8.62
|
| Rate for Payer: Blue Shield of California EPN |
$5.63
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Central Health Plan Commercial |
$11.28
|
| Rate for Payer: Cigna of CA HMO |
$9.87
|
| Rate for Payer: Cigna of CA PPO |
$9.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.64
|
| Rate for Payer: EPIC Health Plan Senior |
$5.64
|
| Rate for Payer: Galaxy Health WC |
$11.98
|
| Rate for Payer: Global Benefits Group Commercial |
$8.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.69
|
| Rate for Payer: InnovAge PACE Commercial |
$7.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.87
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
| Rate for Payer: Networks By Design Commercial |
$9.16
|
| Rate for Payer: Prime Health Services Commercial |
$11.98
|
| Rate for Payer: Riverside University Health System MISP |
$5.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.05
|
| Rate for Payer: United Healthcare All Other HMO |
$7.05
|
| Rate for Payer: United Healthcare HMO Rider |
$7.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.98
|
| Rate for Payer: Vantage Medical Group Senior |
$11.98
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
IP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0777-67
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$12.69 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Blue Shield of California Commercial |
$10.90
|
| Rate for Payer: Blue Shield of California EPN |
$7.11
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Central Health Plan Commercial |
$11.28
|
| Rate for Payer: Cigna of CA HMO |
$9.87
|
| Rate for Payer: Cigna of CA PPO |
$9.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.64
|
| Rate for Payer: EPIC Health Plan Senior |
$5.64
|
| Rate for Payer: Galaxy Health WC |
$11.98
|
| Rate for Payer: Global Benefits Group Commercial |
$8.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
| Rate for Payer: Networks By Design Commercial |
$9.16
|
| Rate for Payer: Prime Health Services Commercial |
$11.98
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 62332-557-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Central Health Plan Commercial |
$1.31
|
| Rate for Payer: Cigna of CA HMO |
$1.15
|
| Rate for Payer: Cigna of CA PPO |
$1.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: EPIC Health Plan Senior |
$0.66
|
| Rate for Payer: Galaxy Health WC |
$1.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.48
|
| Rate for Payer: InnovAge PACE Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: Networks By Design Commercial |
$1.07
|
| Rate for Payer: Prime Health Services Commercial |
$1.39
|
| Rate for Payer: Riverside University Health System MISP |
$0.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO |
$0.82
|
| Rate for Payer: United Healthcare HMO Rider |
$0.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Vantage Medical Group Senior |
$1.39
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 62332-557-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$1.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.83
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Central Health Plan Commercial |
$1.31
|
| Rate for Payer: Cigna of CA HMO |
$1.15
|
| Rate for Payer: Cigna of CA PPO |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: EPIC Health Plan Senior |
$0.66
|
| Rate for Payer: Galaxy Health WC |
$1.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: Networks By Design Commercial |
$1.07
|
| Rate for Payer: Prime Health Services Commercial |
$1.39
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
IP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0777-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$12.69 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Blue Shield of California Commercial |
$10.90
|
| Rate for Payer: Blue Shield of California EPN |
$7.11
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Central Health Plan Commercial |
$11.28
|
| Rate for Payer: Cigna of CA HMO |
$9.87
|
| Rate for Payer: Cigna of CA PPO |
$9.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.64
|
| Rate for Payer: EPIC Health Plan Senior |
$5.64
|
| Rate for Payer: Galaxy Health WC |
$11.98
|
| Rate for Payer: Global Benefits Group Commercial |
$8.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
| Rate for Payer: Networks By Design Commercial |
$9.16
|
| Rate for Payer: Prime Health Services Commercial |
$11.98
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
OP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0777-67
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$12.69 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.57
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.28
|
| Rate for Payer: Blue Shield of California Commercial |
$8.62
|
| Rate for Payer: Blue Shield of California EPN |
$5.63
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Central Health Plan Commercial |
$11.28
|
| Rate for Payer: Cigna of CA HMO |
$9.87
|
| Rate for Payer: Cigna of CA PPO |
$9.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.64
|
| Rate for Payer: EPIC Health Plan Senior |
$5.64
|
| Rate for Payer: Galaxy Health WC |
$11.98
|
| Rate for Payer: Global Benefits Group Commercial |
$8.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.69
|
| Rate for Payer: InnovAge PACE Commercial |
$7.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.87
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
| Rate for Payer: Networks By Design Commercial |
$9.16
|
| Rate for Payer: Prime Health Services Commercial |
$11.98
|
| Rate for Payer: Riverside University Health System MISP |
$5.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.05
|
| Rate for Payer: United Healthcare All Other HMO |
$7.05
|
| Rate for Payer: United Healthcare HMO Rider |
$7.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.98
|
| Rate for Payer: Vantage Medical Group Senior |
$11.98
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 62332-558-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Central Health Plan Commercial |
$1.31
|
| Rate for Payer: Cigna of CA HMO |
$1.15
|
| Rate for Payer: Cigna of CA PPO |
$1.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: EPIC Health Plan Senior |
$0.66
|
| Rate for Payer: Galaxy Health WC |
$1.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.48
|
| Rate for Payer: InnovAge PACE Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: Networks By Design Commercial |
$1.07
|
| Rate for Payer: Prime Health Services Commercial |
$1.39
|
| Rate for Payer: Riverside University Health System MISP |
$0.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO |
$0.82
|
| Rate for Payer: United Healthcare HMO Rider |
$0.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Vantage Medical Group Senior |
$1.39
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
IP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0696-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$12.69 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Blue Shield of California Commercial |
$10.90
|
| Rate for Payer: Blue Shield of California EPN |
$7.11
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Central Health Plan Commercial |
$11.28
|
| Rate for Payer: Cigna of CA HMO |
$9.87
|
| Rate for Payer: Cigna of CA PPO |
$9.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.64
|
| Rate for Payer: EPIC Health Plan Senior |
$5.64
|
| Rate for Payer: Galaxy Health WC |
$11.98
|
| Rate for Payer: Global Benefits Group Commercial |
$8.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
| Rate for Payer: Networks By Design Commercial |
$9.16
|
| Rate for Payer: Prime Health Services Commercial |
$11.98
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
OP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0696-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$12.69 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.57
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.28
|
| Rate for Payer: Blue Shield of California Commercial |
$8.62
|
| Rate for Payer: Blue Shield of California EPN |
$5.63
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Central Health Plan Commercial |
$11.28
|
| Rate for Payer: Cigna of CA HMO |
$9.87
|
| Rate for Payer: Cigna of CA PPO |
$9.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.64
|
| Rate for Payer: EPIC Health Plan Senior |
$5.64
|
| Rate for Payer: Galaxy Health WC |
$11.98
|
| Rate for Payer: Global Benefits Group Commercial |
$8.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.69
|
| Rate for Payer: InnovAge PACE Commercial |
$7.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.87
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
| Rate for Payer: Networks By Design Commercial |
$9.16
|
| Rate for Payer: Prime Health Services Commercial |
$11.98
|
| Rate for Payer: Riverside University Health System MISP |
$5.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.05
|
| Rate for Payer: United Healthcare All Other HMO |
$7.05
|
| Rate for Payer: United Healthcare HMO Rider |
$7.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.98
|
| Rate for Payer: Vantage Medical Group Senior |
$11.98
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 62332-558-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$1.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.83
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Central Health Plan Commercial |
$1.31
|
| Rate for Payer: Cigna of CA HMO |
$1.15
|
| Rate for Payer: Cigna of CA PPO |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: EPIC Health Plan Senior |
$0.66
|
| Rate for Payer: Galaxy Health WC |
$1.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: Networks By Design Commercial |
$1.07
|
| Rate for Payer: Prime Health Services Commercial |
$1.39
|
|
|
SALICYLIC ACID 17 % TOPICAL LIQUID [11323]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 1101725220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
|
|
SALICYLIC ACID 17 % TOPICAL LIQUID [11323]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 1101725220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.56
|
| Rate for Payer: InnovAge PACE Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: Riverside University Health System MISP |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 4858251201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 4858251201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.14
|
| Rate for Payer: InnovAge PACE Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Riverside University Health System MISP |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
HCPCS A9154
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| 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 |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| 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 Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.30
|
| Rate for Payer: InnovAge PACE Commercial |
$0.17
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: Riverside University Health System MISP |
$0.13
|
| 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 |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| 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
|
HCPCS A9154
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| 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: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.30
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
|
|
SARGRAMOSTIM 250 MCG SOLUTION FOR INJECTION [11338]
|
Facility
|
IP
|
$377.55
|
|
|
Service Code
|
HCPCS J2820
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.51 |
| Max. Negotiated Rate |
$339.80 |
| Rate for Payer: Adventist Health Commercial |
$75.51
|
| Rate for Payer: Blue Shield of California Commercial |
$291.85
|
| Rate for Payer: Blue Shield of California EPN |
$190.29
|
| Rate for Payer: Cash Price |
$207.65
|
| Rate for Payer: Central Health Plan Commercial |
$302.04
|
| Rate for Payer: Cigna of CA HMO |
$264.29
|
| Rate for Payer: Cigna of CA PPO |
$264.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$151.02
|
| Rate for Payer: EPIC Health Plan Senior |
$151.02
|
| Rate for Payer: Galaxy Health WC |
$320.92
|
| Rate for Payer: Global Benefits Group Commercial |
$226.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$339.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$251.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$143.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$233.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.51
|
| Rate for Payer: Multiplan Commercial |
$283.16
|
| Rate for Payer: Networks By Design Commercial |
$188.78
|
| Rate for Payer: Prime Health Services Commercial |
$320.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$141.69
|
| Rate for Payer: United Healthcare All Other HMO |
$137.92
|
| Rate for Payer: United Healthcare HMO Rider |
$134.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$123.65
|
|
