|
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
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
NDC 42858-150-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.70
|
| Rate for Payer: Blue Shield of California Commercial |
$6.97
|
| Rate for Payer: Blue Shield of California EPN |
$4.55
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Central Health Plan Commercial |
$9.12
|
| Rate for Payer: Cigna of CA HMO |
$7.98
|
| Rate for Payer: Cigna of CA PPO |
$7.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.56
|
| Rate for Payer: EPIC Health Plan Senior |
$4.56
|
| Rate for Payer: Galaxy Health WC |
$9.69
|
| Rate for Payer: Global Benefits Group Commercial |
$6.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.26
|
| Rate for Payer: InnovAge PACE Commercial |
$5.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: Networks By Design Commercial |
$7.41
|
| Rate for Payer: Prime Health Services Commercial |
$9.69
|
| Rate for Payer: Riverside University Health System MISP |
$4.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.70
|
| Rate for Payer: United Healthcare All Other HMO |
$5.70
|
| Rate for Payer: United Healthcare HMO Rider |
$5.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Vantage Medical Group Senior |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
NDC 45802-580-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.70
|
| Rate for Payer: Blue Shield of California Commercial |
$6.97
|
| Rate for Payer: Blue Shield of California EPN |
$4.55
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Central Health Plan Commercial |
$9.12
|
| Rate for Payer: Cigna of CA HMO |
$7.98
|
| Rate for Payer: Cigna of CA PPO |
$7.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.56
|
| Rate for Payer: EPIC Health Plan Senior |
$4.56
|
| Rate for Payer: Galaxy Health WC |
$9.69
|
| Rate for Payer: Global Benefits Group Commercial |
$6.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.26
|
| Rate for Payer: InnovAge PACE Commercial |
$5.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: Networks By Design Commercial |
$7.41
|
| Rate for Payer: Prime Health Services Commercial |
$9.69
|
| Rate for Payer: Riverside University Health System MISP |
$4.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.70
|
| Rate for Payer: United Healthcare All Other HMO |
$5.70
|
| Rate for Payer: United Healthcare HMO Rider |
$5.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Vantage Medical Group Senior |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-97
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$19.85 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$13.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$10.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.96
|
| Rate for Payer: Blue Shield of California Commercial |
$13.48
|
| Rate for Payer: Blue Shield of California EPN |
$8.80
|
| Rate for Payer: Cash Price |
$12.13
|
| Rate for Payer: Central Health Plan Commercial |
$17.65
|
| Rate for Payer: Cigna of CA HMO |
$15.44
|
| Rate for Payer: Cigna of CA PPO |
$15.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.82
|
| Rate for Payer: EPIC Health Plan Senior |
$8.82
|
| Rate for Payer: Galaxy Health WC |
$18.75
|
| Rate for Payer: Global Benefits Group Commercial |
$13.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.85
|
| Rate for Payer: InnovAge PACE Commercial |
$11.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.44
|
| Rate for Payer: Multiplan Commercial |
$16.55
|
| Rate for Payer: Networks By Design Commercial |
$14.34
|
| Rate for Payer: Prime Health Services Commercial |
$18.75
|
| Rate for Payer: Riverside University Health System MISP |
$8.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.03
|
| Rate for Payer: United Healthcare All Other HMO |
$11.03
|
| Rate for Payer: United Healthcare HMO Rider |
$11.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.75
|
| Rate for Payer: Vantage Medical Group Senior |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$19.39
|
|
|
Service Code
|
NDC 0378-6470-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$17.45 |
| Rate for Payer: Adventist Health Commercial |
$3.88
|
| Rate for Payer: Blue Shield of California Commercial |
$14.99
|
| Rate for Payer: Blue Shield of California EPN |
$9.77
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: Central Health Plan Commercial |
$15.51
|
| Rate for Payer: Cigna of CA HMO |
$13.57
|
| Rate for Payer: Cigna of CA PPO |
$13.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.76
|
| Rate for Payer: EPIC Health Plan Senior |
$7.76
|
| Rate for Payer: Galaxy Health WC |
$16.48
|
| Rate for Payer: Global Benefits Group Commercial |
$11.63
|
| Rate for Payer: Health Management Network EPO/PPO |
$17.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: Multiplan Commercial |
$14.54
|
| Rate for Payer: Networks By Design Commercial |
$12.60
|
| Rate for Payer: Prime Health Services Commercial |
$16.48
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
NDC 45802-580-84
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.70
|
| Rate for Payer: Blue Shield of California Commercial |
$6.97
|
| Rate for Payer: Blue Shield of California EPN |
$4.55
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Central Health Plan Commercial |
$9.12
|
| Rate for Payer: Cigna of CA HMO |
$7.98
|
| Rate for Payer: Cigna of CA PPO |
$7.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.56
|
| Rate for Payer: EPIC Health Plan Senior |
$4.56
|
| Rate for Payer: Galaxy Health WC |
$9.69
|
| Rate for Payer: Global Benefits Group Commercial |
$6.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.26
|
| Rate for Payer: InnovAge PACE Commercial |
$5.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: Networks By Design Commercial |
$7.41
|
| Rate for Payer: Prime Health Services Commercial |
$9.69
|
| Rate for Payer: Riverside University Health System MISP |
$4.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.70
|
| Rate for Payer: United Healthcare All Other HMO |
$5.70
|
| Rate for Payer: United Healthcare HMO Rider |
$5.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Vantage Medical Group Senior |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
NDC 42858-150-91
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California Commercial |
$8.81
|
| Rate for Payer: Blue Shield of California EPN |
$5.75
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Central Health Plan Commercial |
$9.12
|
| Rate for Payer: Cigna of CA HMO |
$7.98
|
| Rate for Payer: Cigna of CA PPO |
$7.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.56
|
| Rate for Payer: EPIC Health Plan Senior |
$4.56
|
| Rate for Payer: Galaxy Health WC |
$9.69
|
| Rate for Payer: Global Benefits Group Commercial |
$6.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: Networks By Design Commercial |
$7.41
|
| Rate for Payer: Prime Health Services Commercial |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
NDC 42858-150-91
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.70
|
| Rate for Payer: Blue Shield of California Commercial |
$6.97
|
| Rate for Payer: Blue Shield of California EPN |
$4.55
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Central Health Plan Commercial |
$9.12
|
| Rate for Payer: Cigna of CA HMO |
$7.98
|
| Rate for Payer: Cigna of CA PPO |
$7.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.56
|
| Rate for Payer: EPIC Health Plan Senior |
$4.56
|
| Rate for Payer: Galaxy Health WC |
$9.69
|
| Rate for Payer: Global Benefits Group Commercial |
$6.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.26
|
| Rate for Payer: InnovAge PACE Commercial |
$5.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: Networks By Design Commercial |
$7.41
|
| Rate for Payer: Prime Health Services Commercial |
$9.69
|
| Rate for Payer: Riverside University Health System MISP |
$4.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.70
|
| Rate for Payer: United Healthcare All Other HMO |
$5.70
|
| Rate for Payer: United Healthcare HMO Rider |
$5.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Vantage Medical Group Senior |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
NDC 45802-580-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California Commercial |
$8.81
|
| Rate for Payer: Blue Shield of California EPN |
$5.75
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Central Health Plan Commercial |
$9.12
|
| Rate for Payer: Cigna of CA HMO |
$7.98
|
| Rate for Payer: Cigna of CA PPO |
$7.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.56
|
| Rate for Payer: EPIC Health Plan Senior |
$4.56
|
| Rate for Payer: Galaxy Health WC |
$9.69
|
| Rate for Payer: Global Benefits Group Commercial |
$6.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: Networks By Design Commercial |
$7.41
|
| Rate for Payer: Prime Health Services Commercial |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
NDC 42858-150-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California Commercial |
$8.81
|
| Rate for Payer: Blue Shield of California EPN |
$5.75
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Central Health Plan Commercial |
$9.12
|
| Rate for Payer: Cigna of CA HMO |
$7.98
|
| Rate for Payer: Cigna of CA PPO |
$7.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.56
|
| Rate for Payer: EPIC Health Plan Senior |
$4.56
|
| Rate for Payer: Galaxy Health WC |
$9.69
|
| Rate for Payer: Global Benefits Group Commercial |
$6.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: Networks By Design Commercial |
$7.41
|
| Rate for Payer: Prime Health Services Commercial |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$19.39
|
|
|
Service Code
|
NDC 0378-6470-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$17.45 |
| Rate for Payer: Adventist Health Commercial |
$3.88
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.54
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$9.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.39
|
| Rate for Payer: Blue Shield of California Commercial |
$11.85
|
| Rate for Payer: Blue Shield of California EPN |
$7.74
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: Central Health Plan Commercial |
$15.51
|
| Rate for Payer: Cigna of CA HMO |
$13.57
|
| Rate for Payer: Cigna of CA PPO |
$13.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.76
|
| Rate for Payer: EPIC Health Plan Senior |
$7.76
|
| Rate for Payer: Galaxy Health WC |
$16.48
|
| Rate for Payer: Global Benefits Group Commercial |
$11.63
|
| Rate for Payer: Health Management Network EPO/PPO |
$17.45
|
| Rate for Payer: InnovAge PACE Commercial |
$9.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.57
|
| Rate for Payer: Multiplan Commercial |
$14.54
|
| Rate for Payer: Networks By Design Commercial |
$12.60
|
| Rate for Payer: Prime Health Services Commercial |
$16.48
|
| Rate for Payer: Riverside University Health System MISP |
$7.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.70
|
| Rate for Payer: United Healthcare All Other HMO |
$9.70
|
| Rate for Payer: United Healthcare HMO Rider |
$9.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.48
|
| Rate for Payer: Vantage Medical Group Senior |
$16.48
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
NDC 45802-580-84
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California Commercial |
$8.81
|
| Rate for Payer: Blue Shield of California EPN |
$5.75
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Central Health Plan Commercial |
$9.12
|
| Rate for Payer: Cigna of CA HMO |
$7.98
|
| Rate for Payer: Cigna of CA PPO |
$7.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.56
|
| Rate for Payer: EPIC Health Plan Senior |
$4.56
|
| Rate for Payer: Galaxy Health WC |
$9.69
|
| Rate for Payer: Global Benefits Group Commercial |
$6.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: Networks By Design Commercial |
$7.41
|
| Rate for Payer: Prime Health Services Commercial |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$19.85 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Blue Shield of California Commercial |
$17.05
|
| Rate for Payer: Blue Shield of California EPN |
$11.12
|
| Rate for Payer: Cash Price |
$12.13
|
| Rate for Payer: Central Health Plan Commercial |
$17.65
|
| Rate for Payer: Cigna of CA HMO |
$15.44
|
| Rate for Payer: Cigna of CA PPO |
$15.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.82
|
| Rate for Payer: EPIC Health Plan Senior |
$8.82
|
| Rate for Payer: Galaxy Health WC |
$18.75
|
| Rate for Payer: Global Benefits Group Commercial |
$13.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$16.55
|
| Rate for Payer: Networks By Design Commercial |
$14.34
|
| Rate for Payer: Prime Health Services Commercial |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$19.85 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$13.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$10.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.96
|
| Rate for Payer: Blue Shield of California Commercial |
$13.48
|
| Rate for Payer: Blue Shield of California EPN |
$8.80
|
| Rate for Payer: Cash Price |
$12.13
|
| Rate for Payer: Central Health Plan Commercial |
$17.65
|
| Rate for Payer: Cigna of CA HMO |
$15.44
|
| Rate for Payer: Cigna of CA PPO |
$15.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.82
|
| Rate for Payer: EPIC Health Plan Senior |
$8.82
|
| Rate for Payer: Galaxy Health WC |
$18.75
|
| Rate for Payer: Global Benefits Group Commercial |
$13.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.85
|
| Rate for Payer: InnovAge PACE Commercial |
$11.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.44
|
| Rate for Payer: Multiplan Commercial |
$16.55
|
| Rate for Payer: Networks By Design Commercial |
$14.34
|
| Rate for Payer: Prime Health Services Commercial |
$18.75
|
| Rate for Payer: Riverside University Health System MISP |
$8.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.03
|
| Rate for Payer: United Healthcare All Other HMO |
$11.03
|
| Rate for Payer: United Healthcare HMO Rider |
$11.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.75
|
| Rate for Payer: Vantage Medical Group Senior |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-97
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$19.85 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Blue Shield of California Commercial |
$17.05
|
| Rate for Payer: Blue Shield of California EPN |
$11.12
|
| Rate for Payer: Cash Price |
$12.13
|
| Rate for Payer: Central Health Plan Commercial |
$17.65
|
| Rate for Payer: Cigna of CA HMO |
$15.44
|
| Rate for Payer: Cigna of CA PPO |
$15.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.82
|
| Rate for Payer: EPIC Health Plan Senior |
$8.82
|
| Rate for Payer: Galaxy Health WC |
$18.75
|
| Rate for Payer: Global Benefits Group Commercial |
$13.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$16.55
|
| Rate for Payer: Networks By Design Commercial |
$14.34
|
| Rate for Payer: Prime Health Services Commercial |
$18.75
|
|
|
SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]
|
Facility
|
OP
|
$630.00
|
|
|
Service Code
|
HCPCS J2850
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.88 |
| Max. Negotiated Rate |
$567.00 |
| Rate for Payer: Adventist Health Commercial |
$126.00
|
| Rate for Payer: Adventist Health Medi-Cal |
$43.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$382.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$48.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$48.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$90.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.88
|
| Rate for Payer: Blue Shield of California Commercial |
$43.32
|
| Rate for Payer: Blue Shield of California EPN |
$39.38
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Central Health Plan Commercial |
$504.00
|
| Rate for Payer: Cigna of CA HMO |
$441.00
|
| Rate for Payer: Cigna of CA PPO |
$441.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$48.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$59.12
|
| Rate for Payer: EPIC Health Plan Senior |
$43.79
|
| Rate for Payer: Galaxy Health WC |
$535.50
|
| Rate for Payer: Global Benefits Group Commercial |
$378.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$567.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$71.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$64.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.79
|
| Rate for Payer: InnovAge PACE Commercial |
$65.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$420.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$70.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$43.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$126.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$58.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$58.68
|
| Rate for Payer: Multiplan Commercial |
$472.50
|
| Rate for Payer: Networks By Design Commercial |
$315.00
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$43.79
|
| Rate for Payer: Prime Health Services Commercial |
$535.50
|
| Rate for Payer: Prime Health Services Medicare |
$46.42
|
| Rate for Payer: Riverside University Health System MISP |
$48.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$378.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$378.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$236.44
|
| Rate for Payer: United Healthcare All Other HMO |
$230.14
|
| Rate for Payer: United Healthcare HMO Rider |
$225.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$206.32
|
| Rate for Payer: Upland Medical Group Pediatric |
$43.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.17
|
| Rate for Payer: Vantage Medical Group Senior |
$48.17
|
|
|
SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]
|
Facility
|
IP
|
$630.00
|
|
|
Service Code
|
HCPCS J2850
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$567.00 |
| Rate for Payer: Adventist Health Commercial |
$126.00
|
| Rate for Payer: Blue Shield of California Commercial |
$486.99
|
| Rate for Payer: Blue Shield of California EPN |
$317.52
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Central Health Plan Commercial |
$504.00
|
| Rate for Payer: Cigna of CA HMO |
$441.00
|
| Rate for Payer: Cigna of CA PPO |
$441.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$252.00
|
| Rate for Payer: EPIC Health Plan Senior |
$252.00
|
| Rate for Payer: Galaxy Health WC |
$535.50
|
| Rate for Payer: Global Benefits Group Commercial |
$378.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$567.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$420.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$240.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$389.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$126.00
|
| Rate for Payer: Multiplan Commercial |
$472.50
|
| Rate for Payer: Networks By Design Commercial |
$315.00
|
| Rate for Payer: Prime Health Services Commercial |
$535.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$236.44
|
| Rate for Payer: United Healthcare All Other HMO |
$230.14
|
| Rate for Payer: United Healthcare HMO Rider |
$225.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$206.32
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 60505-0055-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.01
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Central Health Plan Commercial |
$1.61
|
| Rate for Payer: Cigna of CA HMO |
$1.41
|
| Rate for Payer: Cigna of CA PPO |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Senior |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.71
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Networks By Design Commercial |
$1.31
|
| Rate for Payer: Prime Health Services Commercial |
$1.71
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 60505-0055-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.18
|
| Rate for Payer: Blue Shield of California Commercial |
$1.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Central Health Plan Commercial |
$1.61
|
| Rate for Payer: Cigna of CA HMO |
$1.41
|
| Rate for Payer: Cigna of CA PPO |
$1.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Senior |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.71
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.81
|
| Rate for Payer: InnovAge PACE Commercial |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Networks By Design Commercial |
$1.31
|
| Rate for Payer: Prime Health Services Commercial |
$1.71
|
| Rate for Payer: Riverside University Health System MISP |
$0.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1.71
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 7985401163
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: InnovAge PACE Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 4009310196
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: InnovAge PACE Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 4009310196
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 7431203201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 7985401163
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 7431203201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: InnovAge PACE Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
