|
SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]
|
Facility
OP
|
$0.14
|
|
|
Service Code
|
NDC 4858251201
|
| Hospital Charge Code |
NDG216603
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: BCBS Transplant Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.11
|
| Rate for Payer: IEHP medi-cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: Riverside University Health MISP |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
OP
|
$0.33
|
|
|
Service Code
|
NDC 73090-0800-02
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: BCBS Transplant Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.30
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.25
|
| Rate for Payer: IEHP medi-cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: Riverside University Health MISP |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 6014629157
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 8489800001
|
| Hospital Charge Code |
1719220
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 8489800001
|
| Hospital Charge Code |
1719220
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: BCBS Transplant Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.27
|
| Rate for Payer: IEHP medi-cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: Riverside University Health MISP |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
IP
|
$0.33
|
|
|
Service Code
|
NDC 73090-0800-02
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 6014629157
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: BCBS Transplant Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.27
|
| Rate for Payer: IEHP medi-cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: Riverside University Health MISP |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)
|
Facility
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 58700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,212.08 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11,071.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,830.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,079.84
|
| Rate for Payer: Blue Shield of California EPN |
$2,212.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,537.00
|
| Rate for Payer: United Healthcare All Other HMO |
$19,907.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,444.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,379.00
|
|
|
SAQUINAVIR 500 MG TABLET [40401]
|
Facility
OP
|
$12.02
|
|
|
Service Code
|
NDC 0004-0244-51
|
| Hospital Charge Code |
1710991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$10.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.61
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.61
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.10
|
| Rate for Payer: BCBS Transplant Transplant |
$7.21
|
| Rate for Payer: Blue Shield of California Commercial |
$7.56
|
| Rate for Payer: Blue Shield of California EPN |
$5.88
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: Central Health Plan Commercial |
$9.62
|
| Rate for Payer: Cigna of CA HMO |
$8.41
|
| Rate for Payer: Cigna of CA PPO |
$8.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.81
|
| Rate for Payer: Galaxy Health WC |
$10.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.82
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$9.02
|
| Rate for Payer: IEHP medi-cal |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Multiplan Commercial |
$9.02
|
| Rate for Payer: Networks By Design Commercial |
$7.81
|
| Rate for Payer: Prime Health Services Commercial |
$10.22
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$7.21
|
| Rate for Payer: Riverside University Health MISP |
$4.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.01
|
| Rate for Payer: United Healthcare All Other HMO |
$6.01
|
| Rate for Payer: United Healthcare HMO Rider |
$6.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.22
|
| Rate for Payer: Vantage Medical Group Senior |
$10.22
|
|
|
SAQUINAVIR 500 MG TABLET [40401]
|
Facility
IP
|
$12.02
|
|
|
Service Code
|
NDC 0004-0244-51
|
| Hospital Charge Code |
1710991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$10.82 |
| Rate for Payer: Blue Shield of California Commercial |
$9.02
|
| Rate for Payer: Blue Shield of California EPN |
$6.42
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: Central Health Plan Commercial |
$9.62
|
| Rate for Payer: Cigna of CA HMO |
$8.41
|
| Rate for Payer: Cigna of CA PPO |
$8.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.81
|
| Rate for Payer: Galaxy Health WC |
$10.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Multiplan Commercial |
$9.02
|
| Rate for Payer: Networks By Design Commercial |
$7.81
|
| Rate for Payer: Prime Health Services Commercial |
$10.22
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS PEN INJECTOR [221911]
|
Facility
IP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG221911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$431.29 |
| Max. Negotiated Rate |
$1,940.81 |
| Rate for Payer: Blue Shield of California Commercial |
$1,617.34
|
| Rate for Payer: Blue Shield of California EPN |
$1,151.55
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Central Health Plan Commercial |
$1,725.17
|
| Rate for Payer: Cigna of CA HMO |
$1,509.52
|
| Rate for Payer: Cigna of CA PPO |
$1,509.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$862.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$862.58
|
| Rate for Payer: Galaxy Health WC |
$1,832.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1,293.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,940.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,438.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$431.29
|
| Rate for Payer: Multiplan Commercial |
$1,617.34
|
| Rate for Payer: Networks By Design Commercial |
$1,078.23
|
| Rate for Payer: Prime Health Services Commercial |
$1,832.99
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS PEN INJECTOR [221911]
|
Facility
OP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG221911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$431.29 |
| Max. Negotiated Rate |
$1,940.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,309.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,832.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,186.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,186.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,044.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,274.04
|
| Rate for Payer: BCBS Transplant Transplant |
$1,293.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1,356.41
|
| Rate for Payer: Blue Shield of California EPN |
$1,054.51
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Central Health Plan Commercial |
$1,725.17
|
| Rate for Payer: Cigna of CA HMO |
$1,509.52
|
| Rate for Payer: Cigna of CA PPO |
$1,509.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,832.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$862.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$862.58
|
| Rate for Payer: Galaxy Health WC |
$1,832.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1,293.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,940.81
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,617.34
|
| Rate for Payer: IEHP medi-cal |
$754.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,438.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$431.29
|
| Rate for Payer: Multiplan Commercial |
$1,617.34
|
| Rate for Payer: Networks By Design Commercial |
$1,078.23
|
| Rate for Payer: Prime Health Services Commercial |
$1,832.99
|
| Rate for Payer: Riverside University Health MISP |
$862.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,293.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,293.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,078.23
|
| Rate for Payer: United Healthcare All Other HMO |
$1,078.23
|
| Rate for Payer: United Healthcare HMO Rider |
$1,078.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,078.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,832.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1,832.99
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE [216968]
|
Facility
OP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG216968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$431.29 |
| Max. Negotiated Rate |
$1,940.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,309.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,832.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,186.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,186.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,044.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,274.04
|
| Rate for Payer: BCBS Transplant Transplant |
$1,293.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1,356.41
|
| Rate for Payer: Blue Shield of California EPN |
$1,054.51
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Central Health Plan Commercial |
$1,725.17
|
| Rate for Payer: Cigna of CA HMO |
$1,509.52
|
| Rate for Payer: Cigna of CA PPO |
$1,509.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,832.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$862.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$862.58
|
| Rate for Payer: Galaxy Health WC |
$1,832.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1,293.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,940.81
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,617.34
|
| Rate for Payer: IEHP medi-cal |
$754.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,438.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$431.29
|
| Rate for Payer: Multiplan Commercial |
$1,617.34
|
| Rate for Payer: Networks By Design Commercial |
$1,078.23
|
| Rate for Payer: Prime Health Services Commercial |
$1,832.99
|
| Rate for Payer: Riverside University Health MISP |
$862.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,293.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,293.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,078.23
|
| Rate for Payer: United Healthcare All Other HMO |
$1,078.23
|
| Rate for Payer: United Healthcare HMO Rider |
$1,078.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,078.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,832.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1,832.99
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE [216968]
|
Facility
IP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG216968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$431.29 |
| Max. Negotiated Rate |
$1,940.81 |
| Rate for Payer: Blue Shield of California Commercial |
$1,617.34
|
| Rate for Payer: Blue Shield of California EPN |
$1,151.55
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Central Health Plan Commercial |
$1,725.17
|
| Rate for Payer: Cigna of CA HMO |
$1,509.52
|
| Rate for Payer: Cigna of CA PPO |
$1,509.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$862.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$862.58
|
| Rate for Payer: Galaxy Health WC |
$1,832.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1,293.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,940.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,438.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$431.29
|
| Rate for Payer: Multiplan Commercial |
$1,617.34
|
| Rate for Payer: Networks By Design Commercial |
$1,078.23
|
| Rate for Payer: Prime Health Services Commercial |
$1,832.99
|
|
|
SCHIZOPHRENIA
|
Facility
IP
|
$7,793.67
|
|
|
Service Code
|
APR-DRG 7502
|
| Min. Negotiated Rate |
$6,540.14 |
| Max. Negotiated Rate |
$7,793.67 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,540.14
|
| Rate for Payer: IEHP medi-cal |
$7,793.67
|
|
|
SCHIZOPHRENIA
|
Facility
IP
|
$6,253.36
|
|
|
Service Code
|
APR-DRG 7501
|
| Min. Negotiated Rate |
$5,247.58 |
| Max. Negotiated Rate |
$6,253.36 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,247.58
|
| Rate for Payer: IEHP medi-cal |
$6,253.36
|
|
|
SCHIZOPHRENIA
|
Facility
IP
|
$13,045.96
|
|
|
Service Code
|
APR-DRG 7503
|
| Min. Negotiated Rate |
$10,947.66 |
| Max. Negotiated Rate |
$13,045.96 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,947.66
|
| Rate for Payer: IEHP medi-cal |
$13,045.96
|
|
|
SCHIZOPHRENIA
|
Facility
IP
|
$29,502.24
|
|
|
Service Code
|
APR-DRG 7504
|
| Min. Negotiated Rate |
$24,757.13 |
| Max. Negotiated Rate |
$29,502.24 |
| Rate for Payer: Adventist Health Medi-Cal |
$24,757.13
|
| Rate for Payer: IEHP medi-cal |
$29,502.24
|
|
|
Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluoroscopy) and radiological supervision and interpretation when performed
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 49185
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,025.69 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,025.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,025.69
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,079.84
|
| Rate for Payer: Blue Shield of California EPN |
$2,212.08
|
| Rate for Payer: Caremore Medicare Advantage |
$2,025.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,038.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,734.68
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,025.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,025.69
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,322.13
|
| Rate for Payer: IEHP medi-cal |
$3,342.39
|
| Rate for Payer: IEHP Medicare Advantage |
$2,025.69
|
| Rate for Payer: Innovage PACE Commercial |
$3,038.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,025.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,714.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,714.42
|
| Rate for Payer: Prime Health Services Medicare |
$2,147.23
|
| Rate for Payer: Riverside University Health MISP |
$2,228.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,121.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4,248.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,468.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,257.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
OP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-16
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$19.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$13.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$10.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.03
|
| Rate for Payer: BCBS Transplant Transplant |
$13.24
|
| Rate for Payer: Blue Shield of California Commercial |
$13.88
|
| Rate for Payer: Blue Shield of California EPN |
$10.79
|
| Rate for Payer: Cash Price |
$9.93
|
| 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: EPIC Health Plan Commercial |
$8.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$16.54
|
| Rate for Payer: IEHP medi-cal |
$7.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$16.54
|
| Rate for Payer: Networks By Design Commercial |
$14.34
|
| Rate for Payer: Prime Health Services Commercial |
$18.75
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.24
|
| Rate for Payer: Riverside University Health 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 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 0378-6470-16
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$19.85 |
| Rate for Payer: Blue Shield of California Commercial |
$16.54
|
| Rate for Payer: Blue Shield of California EPN |
$11.78
|
| Rate for Payer: Cash Price |
$9.93
|
| 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: 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: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$16.54
|
| 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
IP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-97
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$19.85 |
| Rate for Payer: Blue Shield of California Commercial |
$16.54
|
| Rate for Payer: Blue Shield of California EPN |
$11.78
|
| Rate for Payer: Cash Price |
$9.93
|
| 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: 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: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$16.54
|
| 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
|
$19.39
|
|
|
Service Code
|
NDC 0378-6470-99
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$17.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.66
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$9.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.46
|
| Rate for Payer: BCBS Transplant Transplant |
$11.63
|
| Rate for Payer: Blue Shield of California Commercial |
$12.20
|
| Rate for Payer: Blue Shield of California EPN |
$9.48
|
| Rate for Payer: Cash Price |
$8.73
|
| 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: EPIC Health Plan Commercial |
$7.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$14.54
|
| Rate for Payer: IEHP medi-cal |
$6.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.93
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$11.63
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$16.48
|
| Rate for Payer: Vantage Medical Group Senior |
$16.48
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
IP
|
$23.00
|
|
|
Service Code
|
NDC 45802-580-01
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.60 |
| Max. Negotiated Rate |
$20.70 |
| Rate for Payer: Blue Shield of California Commercial |
$17.25
|
| Rate for Payer: Blue Shield of California EPN |
$12.28
|
| Rate for Payer: Cash Price |
$10.35
|
| Rate for Payer: Central Health Plan Commercial |
$18.40
|
| Rate for Payer: Cigna of CA HMO |
$16.10
|
| Rate for Payer: Cigna of CA PPO |
$16.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.20
|
| Rate for Payer: Galaxy Health WC |
$19.55
|
| Rate for Payer: Global Benefits Group Commercial |
$13.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$20.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$17.25
|
| Rate for Payer: Networks By Design Commercial |
$14.95
|
| Rate for Payer: Prime Health Services Commercial |
$19.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
IP
|
$19.39
|
|
|
Service Code
|
NDC 0378-6470-99
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$17.45 |
| Rate for Payer: Blue Shield of California Commercial |
$14.54
|
| Rate for Payer: Blue Shield of California EPN |
$10.35
|
| Rate for Payer: Cash Price |
$8.73
|
| 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: 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: 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
|
|
