|
SIMETHICONE 80 MG CHEWABLE TABLET [7227]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 57896-791-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.03
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET [7227]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 57896-791-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET [7227]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 8770170344
|
| 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 |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.04
|
| 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 |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET [7227]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 24385-118-78
|
| 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 |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| 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 |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.03
|
| 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 |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 3877917791
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 3172293747
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 3877917798
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: InnovAge PACE Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Riverside University Health System MISP |
$0.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0395266116
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0395266116
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 3877917798
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 3877917791
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: InnovAge PACE Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Riverside University Health System MISP |
$0.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 3172293747
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
SIMVASTATIN 20 MG TABLET [11365]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 68084-512-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
|
|
SIMVASTATIN 20 MG TABLET [11365]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 68084-512-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.26
|
| Rate for Payer: InnovAge PACE Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
| Rate for Payer: Riverside University Health System MISP |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]
|
Facility
|
IP
|
$156.56
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.31 |
| Max. Negotiated Rate |
$140.90 |
| Rate for Payer: Adventist Health Commercial |
$31.31
|
| Rate for Payer: Blue Shield of California Commercial |
$121.02
|
| Rate for Payer: Blue Shield of California EPN |
$78.91
|
| Rate for Payer: Cash Price |
$86.11
|
| Rate for Payer: Central Health Plan Commercial |
$125.25
|
| Rate for Payer: Cigna of CA HMO |
$109.59
|
| Rate for Payer: Cigna of CA PPO |
$109.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.62
|
| Rate for Payer: EPIC Health Plan Senior |
$62.62
|
| Rate for Payer: Galaxy Health WC |
$133.08
|
| Rate for Payer: Global Benefits Group Commercial |
$93.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$140.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$104.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.65
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$96.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.31
|
| Rate for Payer: Multiplan Commercial |
$117.42
|
| Rate for Payer: Networks By Design Commercial |
$78.28
|
| Rate for Payer: Prime Health Services Commercial |
$133.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$58.76
|
| Rate for Payer: United Healthcare All Other HMO |
$57.19
|
| Rate for Payer: United Healthcare HMO Rider |
$55.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$51.27
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]
|
Facility
|
OP
|
$156.56
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.31 |
| Max. Negotiated Rate |
$286.71 |
| Rate for Payer: Adventist Health Commercial |
$31.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$95.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$133.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$86.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$117.42
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$286.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.99
|
| Rate for Payer: Blue Shield of California Commercial |
$163.86
|
| Rate for Payer: Blue Shield of California EPN |
$148.96
|
| Rate for Payer: Cash Price |
$86.11
|
| Rate for Payer: Cash Price |
$86.11
|
| Rate for Payer: Central Health Plan Commercial |
$125.25
|
| Rate for Payer: Cigna of CA HMO |
$109.59
|
| Rate for Payer: Cigna of CA PPO |
$109.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$133.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$133.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$133.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.62
|
| Rate for Payer: EPIC Health Plan Senior |
$62.62
|
| Rate for Payer: Galaxy Health WC |
$133.08
|
| Rate for Payer: Global Benefits Group Commercial |
$93.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$140.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$143.26
|
| Rate for Payer: InnovAge PACE Commercial |
$78.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$104.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$96.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$109.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$109.59
|
| Rate for Payer: Multiplan Commercial |
$117.42
|
| Rate for Payer: Networks By Design Commercial |
$78.28
|
| Rate for Payer: Prime Health Services Commercial |
$133.08
|
| Rate for Payer: Riverside University Health System MISP |
$62.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$93.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$93.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$58.76
|
| Rate for Payer: United Healthcare All Other HMO |
$57.19
|
| Rate for Payer: United Healthcare HMO Rider |
$55.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$51.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$133.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$133.08
|
| Rate for Payer: Vantage Medical Group Senior |
$133.08
|
|
|
SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]
|
Facility
|
IP
|
$300.49
|
|
|
Service Code
|
HCPCS Q2043
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.10 |
| Max. Negotiated Rate |
$270.44 |
| Rate for Payer: Adventist Health Commercial |
$60.10
|
| Rate for Payer: Blue Shield of California Commercial |
$232.28
|
| Rate for Payer: Blue Shield of California EPN |
$151.45
|
| Rate for Payer: Cash Price |
$165.27
|
| Rate for Payer: Central Health Plan Commercial |
$240.39
|
| Rate for Payer: Cigna of CA HMO |
$210.34
|
| Rate for Payer: Cigna of CA PPO |
$210.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$120.20
|
| Rate for Payer: EPIC Health Plan Senior |
$120.20
|
| Rate for Payer: Galaxy Health WC |
$255.42
|
| Rate for Payer: Global Benefits Group Commercial |
$180.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$270.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$200.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$114.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$186.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.10
|
| Rate for Payer: Multiplan Commercial |
$225.37
|
| Rate for Payer: Networks By Design Commercial |
$150.25
|
| Rate for Payer: Prime Health Services Commercial |
$255.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$112.77
|
| Rate for Payer: United Healthcare All Other HMO |
$109.77
|
| Rate for Payer: United Healthcare HMO Rider |
$107.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$98.41
|
|
|
SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]
|
Facility
|
OP
|
$300.49
|
|
|
Service Code
|
HCPCS Q2043
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.10 |
| Max. Negotiated Rate |
$142,605.15 |
| Rate for Payer: Adventist Health Commercial |
$60.10
|
| Rate for Payer: Adventist Health Medi-Cal |
$55,945.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$182.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$83,918.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61,540.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$55,945.97
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$142,605.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$43,765.97
|
| Rate for Payer: Blue Shield of California Commercial |
$85,602.00
|
| Rate for Payer: Blue Shield of California EPN |
$77,820.00
|
| Rate for Payer: Cash Price |
$165.27
|
| Rate for Payer: Cash Price |
$165.27
|
| Rate for Payer: Central Health Plan Commercial |
$240.39
|
| Rate for Payer: Cigna of CA HMO |
$210.34
|
| Rate for Payer: Cigna of CA PPO |
$210.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69,932.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$61,540.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$61,540.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$75,527.06
|
| Rate for Payer: EPIC Health Plan Senior |
$55,945.97
|
| Rate for Payer: Galaxy Health WC |
$255.42
|
| Rate for Payer: Global Benefits Group Commercial |
$180.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$270.44
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$91,751.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$57,017.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$55,945.97
|
| Rate for Payer: InnovAge PACE Commercial |
$83,918.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$200.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$105,519.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$55,945.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74,967.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74,967.60
|
| Rate for Payer: Multiplan Commercial |
$225.37
|
| Rate for Payer: Networks By Design Commercial |
$150.25
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$55,945.97
|
| Rate for Payer: Prime Health Services Commercial |
$255.42
|
| Rate for Payer: Prime Health Services Medicare |
$59,302.73
|
| Rate for Payer: Riverside University Health System MISP |
$61,540.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$180.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$180.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$112.77
|
| Rate for Payer: United Healthcare All Other HMO |
$109.77
|
| Rate for Payer: United Healthcare HMO Rider |
$107.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$98.41
|
| Rate for Payer: Upland Medical Group Pediatric |
$55,945.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$69,932.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61,540.57
|
| Rate for Payer: Vantage Medical Group Senior |
$61,540.57
|
|
|
SIROLIMUS 0.5 MG TABLET [104764]
|
Facility
|
OP
|
$10.35
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$21.81 |
| Rate for Payer: Adventist Health Commercial |
$2.07
|
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.98
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.92
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.91
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$21.81
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$21.81
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$21.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.69
|
| Rate for Payer: Blue Shield of California Commercial |
$12.95
|
| Rate for Payer: Blue Shield of California Commercial |
$12.95
|
| Rate for Payer: Blue Shield of California Commercial |
$12.95
|
| Rate for Payer: Blue Shield of California EPN |
$11.77
|
| Rate for Payer: Blue Shield of California EPN |
$11.77
|
| Rate for Payer: Blue Shield of California EPN |
$11.77
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$5.69
|
| Rate for Payer: Cash Price |
$5.69
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Central Health Plan Commercial |
$8.28
|
| Rate for Payer: Central Health Plan Commercial |
$3.84
|
| Rate for Payer: Central Health Plan Commercial |
$5.24
|
| Rate for Payer: Cigna of CA HMO |
$4.58
|
| Rate for Payer: Cigna of CA HMO |
$3.36
|
| Rate for Payer: Cigna of CA HMO |
$7.25
|
| Rate for Payer: Cigna of CA PPO |
$4.58
|
| Rate for Payer: Cigna of CA PPO |
$7.25
|
| Rate for Payer: Cigna of CA PPO |
$3.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.14
|
| Rate for Payer: EPIC Health Plan Senior |
$1.92
|
| Rate for Payer: EPIC Health Plan Senior |
$4.14
|
| Rate for Payer: EPIC Health Plan Senior |
$2.62
|
| Rate for Payer: Galaxy Health WC |
$5.57
|
| Rate for Payer: Galaxy Health WC |
$8.80
|
| Rate for Payer: Galaxy Health WC |
$4.08
|
| Rate for Payer: Global Benefits Group Commercial |
$6.21
|
| Rate for Payer: Global Benefits Group Commercial |
$3.93
|
| Rate for Payer: Global Benefits Group Commercial |
$2.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$9.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.14
|
| Rate for Payer: InnovAge PACE Commercial |
$5.17
|
| Rate for Payer: InnovAge PACE Commercial |
$2.40
|
| Rate for Payer: InnovAge PACE Commercial |
$3.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.58
|
| Rate for Payer: Multiplan Commercial |
$4.91
|
| Rate for Payer: Multiplan Commercial |
$7.76
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Networks By Design Commercial |
$5.17
|
| Rate for Payer: Networks By Design Commercial |
$3.27
|
| Rate for Payer: Networks By Design Commercial |
$2.40
|
| Rate for Payer: Prime Health Services Commercial |
$4.08
|
| Rate for Payer: Prime Health Services Commercial |
$5.57
|
| Rate for Payer: Prime Health Services Commercial |
$8.80
|
| Rate for Payer: Riverside University Health System MISP |
$2.62
|
| Rate for Payer: Riverside University Health System MISP |
$1.92
|
| Rate for Payer: Riverside University Health System MISP |
$4.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.88
|
| Rate for Payer: United Healthcare All Other HMO |
$3.78
|
| Rate for Payer: United Healthcare All Other HMO |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO |
$2.39
|
| Rate for Payer: United Healthcare HMO Rider |
$1.72
|
| Rate for Payer: United Healthcare HMO Rider |
$3.70
|
| Rate for Payer: United Healthcare HMO Rider |
$2.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$8.80
|
| Rate for Payer: Vantage Medical Group Senior |
$5.57
|
|
|
SIROLIMUS 0.5 MG TABLET [104764]
|
Facility
|
IP
|
$6.55
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$5.89 |
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$2.07
|
| Rate for Payer: Blue Shield of California Commercial |
$5.06
|
| Rate for Payer: Blue Shield of California Commercial |
$3.71
|
| Rate for Payer: Blue Shield of California Commercial |
$8.00
|
| Rate for Payer: Blue Shield of California EPN |
$5.22
|
| Rate for Payer: Blue Shield of California EPN |
$3.30
|
| Rate for Payer: Blue Shield of California EPN |
$2.42
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$5.69
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Central Health Plan Commercial |
$3.84
|
| Rate for Payer: Central Health Plan Commercial |
$8.28
|
| Rate for Payer: Central Health Plan Commercial |
$5.24
|
| Rate for Payer: Cigna of CA HMO |
$4.58
|
| Rate for Payer: Cigna of CA HMO |
$7.25
|
| Rate for Payer: Cigna of CA HMO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$4.58
|
| Rate for Payer: Cigna of CA PPO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$7.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.14
|
| Rate for Payer: EPIC Health Plan Senior |
$1.92
|
| Rate for Payer: EPIC Health Plan Senior |
$4.14
|
| Rate for Payer: EPIC Health Plan Senior |
$2.62
|
| Rate for Payer: Galaxy Health WC |
$4.08
|
| Rate for Payer: Galaxy Health WC |
$8.80
|
| Rate for Payer: Galaxy Health WC |
$5.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.88
|
| Rate for Payer: Global Benefits Group Commercial |
$6.21
|
| Rate for Payer: Global Benefits Group Commercial |
$3.93
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$9.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.07
|
| Rate for Payer: Multiplan Commercial |
$4.91
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$7.76
|
| Rate for Payer: Networks By Design Commercial |
$3.27
|
| Rate for Payer: Networks By Design Commercial |
$5.17
|
| Rate for Payer: Networks By Design Commercial |
$2.40
|
| Rate for Payer: Prime Health Services Commercial |
$4.08
|
| Rate for Payer: Prime Health Services Commercial |
$5.57
|
| Rate for Payer: Prime Health Services Commercial |
$8.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO |
$3.78
|
| Rate for Payer: United Healthcare All Other HMO |
$2.39
|
| Rate for Payer: United Healthcare HMO Rider |
$3.70
|
| Rate for Payer: United Healthcare HMO Rider |
$1.72
|
| Rate for Payer: United Healthcare HMO Rider |
$2.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.39
|
|
|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
|
IP
|
$21.05
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.21 |
| Max. Negotiated Rate |
$18.95 |
| Rate for Payer: Adventist Health Commercial |
$4.21
|
| Rate for Payer: Adventist Health Commercial |
$2.41
|
| Rate for Payer: Blue Shield of California Commercial |
$16.27
|
| Rate for Payer: Blue Shield of California Commercial |
$9.31
|
| Rate for Payer: Blue Shield of California EPN |
$6.07
|
| Rate for Payer: Blue Shield of California EPN |
$10.61
|
| Rate for Payer: Cash Price |
$11.58
|
| Rate for Payer: Cash Price |
$6.62
|
| Rate for Payer: Central Health Plan Commercial |
$16.84
|
| Rate for Payer: Central Health Plan Commercial |
$9.63
|
| Rate for Payer: Cigna of CA HMO |
$8.43
|
| Rate for Payer: Cigna of CA HMO |
$14.73
|
| Rate for Payer: Cigna of CA PPO |
$8.43
|
| Rate for Payer: Cigna of CA PPO |
$14.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: EPIC Health Plan Senior |
$4.82
|
| Rate for Payer: EPIC Health Plan Senior |
$8.42
|
| Rate for Payer: Galaxy Health WC |
$10.23
|
| Rate for Payer: Galaxy Health WC |
$17.89
|
| Rate for Payer: Global Benefits Group Commercial |
$12.63
|
| Rate for Payer: Global Benefits Group Commercial |
$7.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$18.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.41
|
| Rate for Payer: Multiplan Commercial |
$9.03
|
| Rate for Payer: Multiplan Commercial |
$15.79
|
| Rate for Payer: Networks By Design Commercial |
$6.02
|
| Rate for Payer: Networks By Design Commercial |
$10.53
|
| Rate for Payer: Prime Health Services Commercial |
$17.89
|
| Rate for Payer: Prime Health Services Commercial |
$10.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.90
|
| Rate for Payer: United Healthcare All Other HMO |
$7.69
|
| Rate for Payer: United Healthcare All Other HMO |
$4.40
|
| Rate for Payer: United Healthcare HMO Rider |
$4.30
|
| Rate for Payer: United Healthcare HMO Rider |
$7.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.89
|
|
|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
|
OP
|
$21.05
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$21.81 |
| Rate for Payer: Adventist Health Commercial |
$4.21
|
| Rate for Payer: Adventist Health Commercial |
$2.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$12.78
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$21.81
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$21.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.69
|
| Rate for Payer: Blue Shield of California Commercial |
$12.95
|
| Rate for Payer: Blue Shield of California Commercial |
$12.95
|
| Rate for Payer: Blue Shield of California EPN |
$11.77
|
| Rate for Payer: Blue Shield of California EPN |
$11.77
|
| Rate for Payer: Cash Price |
$11.58
|
| Rate for Payer: Cash Price |
$11.58
|
| Rate for Payer: Cash Price |
$6.62
|
| Rate for Payer: Cash Price |
$6.62
|
| Rate for Payer: Central Health Plan Commercial |
$16.84
|
| Rate for Payer: Central Health Plan Commercial |
$9.63
|
| Rate for Payer: Cigna of CA HMO |
$8.43
|
| Rate for Payer: Cigna of CA HMO |
$14.73
|
| Rate for Payer: Cigna of CA PPO |
$14.73
|
| Rate for Payer: Cigna of CA PPO |
$8.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$17.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.82
|
| Rate for Payer: EPIC Health Plan Senior |
$4.82
|
| Rate for Payer: EPIC Health Plan Senior |
$8.42
|
| Rate for Payer: Galaxy Health WC |
$17.89
|
| Rate for Payer: Galaxy Health WC |
$10.23
|
| Rate for Payer: Global Benefits Group Commercial |
$12.63
|
| Rate for Payer: Global Benefits Group Commercial |
$7.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$18.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.14
|
| Rate for Payer: InnovAge PACE Commercial |
$6.02
|
| Rate for Payer: InnovAge PACE Commercial |
$10.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.73
|
| Rate for Payer: Multiplan Commercial |
$9.03
|
| Rate for Payer: Multiplan Commercial |
$15.79
|
| Rate for Payer: Networks By Design Commercial |
$6.02
|
| Rate for Payer: Networks By Design Commercial |
$10.53
|
| Rate for Payer: Prime Health Services Commercial |
$17.89
|
| Rate for Payer: Prime Health Services Commercial |
$10.23
|
| Rate for Payer: Riverside University Health System MISP |
$4.82
|
| Rate for Payer: Riverside University Health System MISP |
$8.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.52
|
| Rate for Payer: United Healthcare All Other HMO |
$7.69
|
| Rate for Payer: United Healthcare All Other HMO |
$4.40
|
| Rate for Payer: United Healthcare HMO Rider |
$4.30
|
| Rate for Payer: United Healthcare HMO Rider |
$7.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.89
|
| Rate for Payer: Vantage Medical Group Senior |
$17.89
|
| Rate for Payer: Vantage Medical Group Senior |
$10.23
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
|
IP
|
$5.40
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Adventist Health Commercial |
$3.33
|
| Rate for Payer: Blue Shield of California Commercial |
$4.17
|
| Rate for Payer: Blue Shield of California Commercial |
$12.88
|
| Rate for Payer: Blue Shield of California EPN |
$8.40
|
| Rate for Payer: Blue Shield of California EPN |
$2.72
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$9.16
|
| Rate for Payer: Central Health Plan Commercial |
$4.32
|
| Rate for Payer: Central Health Plan Commercial |
$13.33
|
| Rate for Payer: Cigna of CA HMO |
$11.66
|
| Rate for Payer: Cigna of CA HMO |
$3.78
|
| Rate for Payer: Cigna of CA PPO |
$11.66
|
| Rate for Payer: Cigna of CA PPO |
$3.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: EPIC Health Plan Senior |
$6.66
|
| Rate for Payer: EPIC Health Plan Senior |
$2.16
|
| Rate for Payer: Galaxy Health WC |
$14.16
|
| Rate for Payer: Galaxy Health WC |
$4.59
|
| Rate for Payer: Global Benefits Group Commercial |
$3.24
|
| Rate for Payer: Global Benefits Group Commercial |
$10.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.33
|
| Rate for Payer: Multiplan Commercial |
$12.49
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Networks By Design Commercial |
$8.33
|
| Rate for Payer: Networks By Design Commercial |
$2.70
|
| Rate for Payer: Prime Health Services Commercial |
$4.59
|
| Rate for Payer: Prime Health Services Commercial |
$14.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.03
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$6.09
|
| Rate for Payer: United Healthcare HMO Rider |
$5.95
|
| Rate for Payer: United Healthcare HMO Rider |
$1.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.77
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
|
OP
|
$5.40
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$21.81 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Adventist Health Commercial |
$3.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$21.81
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$21.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.69
|
| Rate for Payer: Blue Shield of California Commercial |
$12.95
|
| Rate for Payer: Blue Shield of California Commercial |
$12.95
|
| Rate for Payer: Blue Shield of California EPN |
$11.77
|
| Rate for Payer: Blue Shield of California EPN |
$11.77
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$9.16
|
| Rate for Payer: Cash Price |
$9.16
|
| Rate for Payer: Central Health Plan Commercial |
$4.32
|
| Rate for Payer: Central Health Plan Commercial |
$13.33
|
| Rate for Payer: Cigna of CA HMO |
$11.66
|
| Rate for Payer: Cigna of CA HMO |
$3.78
|
| Rate for Payer: Cigna of CA PPO |
$3.78
|
| Rate for Payer: Cigna of CA PPO |
$11.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.59
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.66
|
| Rate for Payer: EPIC Health Plan Senior |
$6.66
|
| Rate for Payer: EPIC Health Plan Senior |
$2.16
|
| Rate for Payer: Galaxy Health WC |
$4.59
|
| Rate for Payer: Galaxy Health WC |
$14.16
|
| Rate for Payer: Global Benefits Group Commercial |
$3.24
|
| Rate for Payer: Global Benefits Group Commercial |
$10.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.14
|
| Rate for Payer: InnovAge PACE Commercial |
$8.33
|
| Rate for Payer: InnovAge PACE Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.78
|
| Rate for Payer: Multiplan Commercial |
$12.49
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Networks By Design Commercial |
$8.33
|
| Rate for Payer: Networks By Design Commercial |
$2.70
|
| Rate for Payer: Prime Health Services Commercial |
$4.59
|
| Rate for Payer: Prime Health Services Commercial |
$14.16
|
| Rate for Payer: Riverside University Health System MISP |
$6.66
|
| Rate for Payer: Riverside University Health System MISP |
$2.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.25
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$6.09
|
| Rate for Payer: United Healthcare HMO Rider |
$5.95
|
| Rate for Payer: United Healthcare HMO Rider |
$1.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$14.16
|
|
|
SITAGLIPTIN 100 MG TABLET [240314]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 70710-1901-3
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.40
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Central Health Plan Commercial |
$2.56
|
| Rate for Payer: Cigna of CA HMO |
$2.05
|
| Rate for Payer: Cigna of CA PPO |
$2.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Senior |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.88
|
| Rate for Payer: InnovAge PACE Commercial |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
| Rate for Payer: Riverside University Health System MISP |
$1.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.60
|
| Rate for Payer: United Healthcare All Other HMO |
$1.60
|
| Rate for Payer: United Healthcare HMO Rider |
$1.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
