|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
OP
|
$21.05
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1715200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$38.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$16.57
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.89
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.62
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$34.73
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$34.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.02
|
| Rate for Payer: BCBS Transplant Transplant |
$12.63
|
| Rate for Payer: BCBS Transplant Transplant |
$10.50
|
| Rate for Payer: Blue Shield of California Commercial |
$20.55
|
| Rate for Payer: Blue Shield of California Commercial |
$20.55
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Central Health Plan Commercial |
$16.84
|
| Rate for Payer: Central Health Plan Commercial |
$14.00
|
| Rate for Payer: Cigna of CA HMO |
$12.25
|
| Rate for Payer: Cigna of CA HMO |
$14.74
|
| Rate for Payer: Cigna of CA PPO |
$12.25
|
| Rate for Payer: Cigna of CA PPO |
$14.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.00
|
| Rate for Payer: Galaxy Health WC |
$17.89
|
| Rate for Payer: Galaxy Health WC |
$14.88
|
| Rate for Payer: Global Benefits Group Commercial |
$10.50
|
| Rate for Payer: Global Benefits Group Commercial |
$12.63
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.75
|
| Rate for Payer: Health Management Network EPO/PPO |
$18.94
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$13.12
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$15.79
|
| Rate for Payer: IEHP medi-cal |
$1.34
|
| Rate for Payer: IEHP medi-cal |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.21
|
| Rate for Payer: Multiplan Commercial |
$13.12
|
| Rate for Payer: Multiplan Commercial |
$15.79
|
| Rate for Payer: Networks By Design Commercial |
$10.52
|
| Rate for Payer: Networks By Design Commercial |
$8.75
|
| Rate for Payer: Prime Health Services Commercial |
$14.88
|
| Rate for Payer: Prime Health Services Commercial |
$17.89
|
| Rate for Payer: Riverside University Health MISP |
$7.00
|
| Rate for Payer: Riverside University Health MISP |
$8.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.52
|
| Rate for Payer: United Healthcare All Other HMO |
$10.52
|
| Rate for Payer: United Healthcare All Other HMO |
$8.75
|
| Rate for Payer: United Healthcare HMO Rider |
$8.75
|
| Rate for Payer: United Healthcare HMO Rider |
$10.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.88
|
| Rate for Payer: Vantage Medical Group Senior |
$14.88
|
| Rate for Payer: Vantage Medical Group Senior |
$17.89
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
IP
|
$16.66
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1711808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$14.99 |
| Rate for Payer: Blue Shield of California Commercial |
$12.50
|
| Rate for Payer: Blue Shield of California Commercial |
$6.75
|
| Rate for Payer: Blue Shield of California EPN |
$4.81
|
| Rate for Payer: Blue Shield of California EPN |
$8.90
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Central Health Plan Commercial |
$7.20
|
| 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 |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$11.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.60
|
| Rate for Payer: Galaxy Health WC |
$14.16
|
| Rate for Payer: Galaxy Health WC |
$7.65
|
| Rate for Payer: Global Benefits Group Commercial |
$10.00
|
| Rate for Payer: Global Benefits Group Commercial |
$5.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$12.50
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Networks By Design Commercial |
$8.33
|
| Rate for Payer: Networks By Design Commercial |
$4.50
|
| Rate for Payer: Prime Health Services Commercial |
$7.65
|
| Rate for Payer: Prime Health Services Commercial |
$14.16
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
OP
|
$16.66
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1711808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$38.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$16.57
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.95
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$34.73
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$34.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.02
|
| Rate for Payer: BCBS Transplant Transplant |
$10.00
|
| Rate for Payer: BCBS Transplant Transplant |
$5.40
|
| Rate for Payer: Blue Shield of California Commercial |
$20.55
|
| Rate for Payer: Blue Shield of California Commercial |
$20.55
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Central Health Plan Commercial |
$13.33
|
| Rate for Payer: Central Health Plan Commercial |
$7.20
|
| Rate for Payer: Cigna of CA HMO |
$11.66
|
| Rate for Payer: Cigna of CA HMO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$11.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.60
|
| Rate for Payer: Galaxy Health WC |
$7.65
|
| Rate for Payer: Galaxy Health WC |
$14.16
|
| Rate for Payer: Global Benefits Group Commercial |
$10.00
|
| Rate for Payer: Global Benefits Group Commercial |
$5.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.99
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$12.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.75
|
| Rate for Payer: IEHP medi-cal |
$1.34
|
| Rate for Payer: IEHP medi-cal |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.33
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Multiplan Commercial |
$12.50
|
| Rate for Payer: Networks By Design Commercial |
$4.50
|
| Rate for Payer: Networks By Design Commercial |
$8.33
|
| Rate for Payer: Prime Health Services Commercial |
$14.16
|
| Rate for Payer: Prime Health Services Commercial |
$7.65
|
| Rate for Payer: Riverside University Health MISP |
$3.60
|
| Rate for Payer: Riverside University Health MISP |
$6.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.33
|
| Rate for Payer: United Healthcare All Other HMO |
$8.33
|
| Rate for Payer: United Healthcare All Other HMO |
$4.50
|
| Rate for Payer: United Healthcare HMO Rider |
$8.33
|
| Rate for Payer: United Healthcare HMO Rider |
$4.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.65
|
| Rate for Payer: Vantage Medical Group Senior |
$14.16
|
| Rate for Payer: Vantage Medical Group Senior |
$7.65
|
|
|
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION [233123]
|
Facility
IP
|
$8,512.06
|
|
|
Service Code
|
NDC 80803-153-50
|
| Hospital Charge Code |
ERX233123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,702.41 |
| Max. Negotiated Rate |
$7,660.85 |
| Rate for Payer: Blue Shield of California Commercial |
$6,384.04
|
| Rate for Payer: Blue Shield of California EPN |
$4,545.44
|
| Rate for Payer: Cash Price |
$3,830.43
|
| Rate for Payer: Central Health Plan Commercial |
$6,809.65
|
| Rate for Payer: Cigna of CA HMO |
$5,958.44
|
| Rate for Payer: Cigna of CA PPO |
$5,958.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,404.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,404.82
|
| Rate for Payer: Galaxy Health WC |
$7,235.25
|
| Rate for Payer: Global Benefits Group Commercial |
$5,107.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$7,660.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,677.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,702.41
|
| Rate for Payer: Multiplan Commercial |
$6,384.04
|
| Rate for Payer: Networks By Design Commercial |
$4,256.03
|
| Rate for Payer: Prime Health Services Commercial |
$7,235.25
|
|
|
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION [233123]
|
Facility
OP
|
$8,512.06
|
|
|
Service Code
|
NDC 80803-153-50
|
| Hospital Charge Code |
ERX233123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,702.41 |
| Max. Negotiated Rate |
$7,660.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5,169.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,235.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,681.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,681.63
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,121.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,028.93
|
| Rate for Payer: BCBS Transplant Transplant |
$5,107.24
|
| Rate for Payer: Blue Shield of California Commercial |
$5,354.09
|
| Rate for Payer: Blue Shield of California EPN |
$4,162.40
|
| Rate for Payer: Cash Price |
$3,830.43
|
| Rate for Payer: Cash Price |
$3,830.43
|
| Rate for Payer: Central Health Plan Commercial |
$6,809.65
|
| Rate for Payer: Cigna of CA HMO |
$5,958.44
|
| Rate for Payer: Cigna of CA PPO |
$5,958.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,235.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,404.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,404.82
|
| Rate for Payer: Galaxy Health WC |
$7,235.25
|
| Rate for Payer: Global Benefits Group Commercial |
$5,107.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$7,660.85
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6,384.04
|
| Rate for Payer: IEHP medi-cal |
$2,979.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,677.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,702.41
|
| Rate for Payer: Multiplan Commercial |
$6,384.04
|
| Rate for Payer: Networks By Design Commercial |
$4,256.03
|
| Rate for Payer: Prime Health Services Commercial |
$7,235.25
|
| Rate for Payer: Riverside University Health MISP |
$3,404.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5,107.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5,107.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,256.03
|
| Rate for Payer: United Healthcare All Other HMO |
$4,256.03
|
| Rate for Payer: United Healthcare HMO Rider |
$4,256.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,256.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,235.25
|
| Rate for Payer: Vantage Medical Group Senior |
$7,235.25
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0277-31
|
| Hospital Charge Code |
1711892
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$19.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$13.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$10.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.93
|
| Rate for Payer: BCBS Transplant Transplant |
$13.13
|
| Rate for Payer: Blue Shield of California Commercial |
$13.77
|
| Rate for Payer: Blue Shield of California EPN |
$10.70
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Central Health Plan Commercial |
$17.51
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.70
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$16.42
|
| Rate for Payer: IEHP medi-cal |
$7.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$16.42
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: Riverside University Health MISP |
$8.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0277-31
|
| Hospital Charge Code |
1711892
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$19.70 |
| Rate for Payer: Blue Shield of California Commercial |
$16.42
|
| Rate for Payer: Blue Shield of California EPN |
$11.69
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Central Health Plan Commercial |
$17.51
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$16.42
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0277-01
|
| Hospital Charge Code |
1711892
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$19.70 |
| Rate for Payer: Blue Shield of California Commercial |
$16.42
|
| Rate for Payer: Blue Shield of California EPN |
$11.69
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Central Health Plan Commercial |
$17.51
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$16.42
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0277-01
|
| Hospital Charge Code |
1711892
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$19.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$13.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$10.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.93
|
| Rate for Payer: BCBS Transplant Transplant |
$13.13
|
| Rate for Payer: Blue Shield of California Commercial |
$13.77
|
| Rate for Payer: Blue Shield of California EPN |
$10.70
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Central Health Plan Commercial |
$17.51
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.70
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$16.42
|
| Rate for Payer: IEHP medi-cal |
$7.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$16.42
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: Riverside University Health MISP |
$8.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0221-31
|
| Hospital Charge Code |
1711890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$19.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$13.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$10.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.93
|
| Rate for Payer: BCBS Transplant Transplant |
$13.13
|
| Rate for Payer: Blue Shield of California Commercial |
$13.77
|
| Rate for Payer: Blue Shield of California EPN |
$10.70
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Central Health Plan Commercial |
$17.51
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.70
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$16.42
|
| Rate for Payer: IEHP medi-cal |
$7.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$16.42
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: Riverside University Health MISP |
$8.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0221-31
|
| Hospital Charge Code |
1711890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$19.70 |
| Rate for Payer: Blue Shield of California Commercial |
$16.42
|
| Rate for Payer: Blue Shield of California EPN |
$11.69
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Central Health Plan Commercial |
$17.51
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$16.42
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0112-28
|
| Hospital Charge Code |
1711891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$19.70 |
| Rate for Payer: Blue Shield of California Commercial |
$16.42
|
| Rate for Payer: Blue Shield of California EPN |
$11.69
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Central Health Plan Commercial |
$17.51
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$16.42
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0112-31
|
| Hospital Charge Code |
1711891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$19.70 |
| Rate for Payer: Blue Shield of California Commercial |
$16.42
|
| Rate for Payer: Blue Shield of California EPN |
$11.69
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Central Health Plan Commercial |
$17.51
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$16.42
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0112-28
|
| Hospital Charge Code |
1711891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$19.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$13.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$10.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.93
|
| Rate for Payer: BCBS Transplant Transplant |
$13.13
|
| Rate for Payer: Blue Shield of California Commercial |
$13.77
|
| Rate for Payer: Blue Shield of California EPN |
$10.70
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Central Health Plan Commercial |
$17.51
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.70
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$16.42
|
| Rate for Payer: IEHP medi-cal |
$7.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$16.42
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: Riverside University Health MISP |
$8.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0112-31
|
| Hospital Charge Code |
1711891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$19.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$13.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$10.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.93
|
| Rate for Payer: BCBS Transplant Transplant |
$13.13
|
| Rate for Payer: Blue Shield of California Commercial |
$13.77
|
| Rate for Payer: Blue Shield of California EPN |
$10.70
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Central Health Plan Commercial |
$17.51
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$19.70
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$16.42
|
| Rate for Payer: IEHP medi-cal |
$7.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$16.42
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: Riverside University Health MISP |
$8.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
IP
|
$21,408.24
|
|
|
Service Code
|
APR-DRG 3122
|
| Min. Negotiated Rate |
$17,964.96 |
| Max. Negotiated Rate |
$21,408.24 |
| Rate for Payer: Adventist Health Medi-Cal |
$17,964.96
|
| Rate for Payer: IEHP medi-cal |
$21,408.24
|
|
|
SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
IP
|
$36,161.37
|
|
|
Service Code
|
APR-DRG 3123
|
| Min. Negotiated Rate |
$30,345.20 |
| Max. Negotiated Rate |
$36,161.37 |
| Rate for Payer: Adventist Health Medi-Cal |
$30,345.20
|
| Rate for Payer: IEHP medi-cal |
$36,161.37
|
|
|
SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
IP
|
$73,337.16
|
|
|
Service Code
|
APR-DRG 3124
|
| Min. Negotiated Rate |
$61,541.68 |
| Max. Negotiated Rate |
$73,337.16 |
| Rate for Payer: Adventist Health Medi-Cal |
$61,541.68
|
| Rate for Payer: IEHP medi-cal |
$73,337.16
|
|
|
SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
IP
|
$13,363.64
|
|
|
Service Code
|
APR-DRG 3121
|
| Min. Negotiated Rate |
$11,214.24 |
| Max. Negotiated Rate |
$13,363.64 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,214.24
|
| Rate for Payer: IEHP medi-cal |
$13,363.64
|
|
|
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES
|
Facility
IP
|
$62,106.47
|
|
|
Service Code
|
APR-DRG 3614
|
| Min. Negotiated Rate |
$52,117.32 |
| Max. Negotiated Rate |
$62,106.47 |
| Rate for Payer: Adventist Health Medi-Cal |
$52,117.32
|
| Rate for Payer: IEHP medi-cal |
$62,106.47
|
|
|
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES
|
Facility
IP
|
$20,256.35
|
|
|
Service Code
|
APR-DRG 3612
|
| Min. Negotiated Rate |
$16,998.34 |
| Max. Negotiated Rate |
$20,256.35 |
| Rate for Payer: Adventist Health Medi-Cal |
$16,998.34
|
| Rate for Payer: IEHP medi-cal |
$20,256.35
|
|
|
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES
|
Facility
IP
|
$30,887.73
|
|
|
Service Code
|
APR-DRG 3613
|
| Min. Negotiated Rate |
$25,919.77 |
| Max. Negotiated Rate |
$30,887.73 |
| Rate for Payer: Adventist Health Medi-Cal |
$25,919.77
|
| Rate for Payer: IEHP medi-cal |
$30,887.73
|
|
|
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES
|
Facility
IP
|
$16,308.12
|
|
|
Service Code
|
APR-DRG 3611
|
| Min. Negotiated Rate |
$13,685.14 |
| Max. Negotiated Rate |
$16,308.12 |
| Rate for Payer: Adventist Health Medi-Cal |
$13,685.14
|
| Rate for Payer: IEHP medi-cal |
$16,308.12
|
|
|
SKIN ULCERS
|
Facility
IP
|
$20,544.65
|
|
|
Service Code
|
APR-DRG 3804
|
| Min. Negotiated Rate |
$17,240.27 |
| Max. Negotiated Rate |
$20,544.65 |
| Rate for Payer: Adventist Health Medi-Cal |
$17,240.27
|
| Rate for Payer: IEHP medi-cal |
$20,544.65
|
|
|
SKIN ULCERS
|
Facility
IP
|
$6,222.66
|
|
|
Service Code
|
APR-DRG 3801
|
| Min. Negotiated Rate |
$5,221.81 |
| Max. Negotiated Rate |
$6,222.66 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,221.81
|
| Rate for Payer: IEHP medi-cal |
$6,222.66
|
|
