|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 8613
|
| Min. Negotiated Rate |
$8,358.04 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$8,358.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$9,959.99
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 8612
|
| Min. Negotiated Rate |
$5,974.51 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,974.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$7,119.63
|
|
|
SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 8611
|
| Min. Negotiated Rate |
$3,447.61 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$3,447.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$4,108.40
|
|
|
SILDENAFIL 25 MG TABLET [22836]
|
Facility
IP
|
$99.92
|
|
|
Service Code
|
NDC 0069-4200-30
|
| Hospital Charge Code |
1710917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.98 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$74.94
|
| Rate for Payer: Blue Shield of California EPN |
$53.36
|
| Rate for Payer: Cash Price |
$44.96
|
| Rate for Payer: Cash Price |
$44.96
|
| Rate for Payer: Central Health Plan Commercial |
$79.94
|
| Rate for Payer: Cigna of CA HMO |
$69.94
|
| Rate for Payer: Cigna of CA PPO |
$69.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.97
|
| Rate for Payer: Galaxy Health WC |
$84.93
|
| Rate for Payer: Global Benefits Group Commercial |
$59.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$89.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$66.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.98
|
| Rate for Payer: Multiplan Commercial |
$74.94
|
| Rate for Payer: Networks By Design Commercial |
$64.95
|
| Rate for Payer: Prime Health Services Commercial |
$84.93
|
|
|
SILDENAFIL 25 MG TABLET [22836]
|
Facility
OP
|
$99.92
|
|
|
Service Code
|
NDC 0069-4200-30
|
| Hospital Charge Code |
1710917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.98 |
| Max. Negotiated Rate |
$89.93 |
| Rate for Payer: Aetna of CA HMO/PPO |
$60.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$84.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$54.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$54.96
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$48.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.03
|
| Rate for Payer: BCBS Transplant Transplant |
$59.95
|
| Rate for Payer: Blue Shield of California Commercial |
$62.85
|
| Rate for Payer: Blue Shield of California EPN |
$48.86
|
| Rate for Payer: Cash Price |
$44.96
|
| Rate for Payer: Central Health Plan Commercial |
$79.94
|
| Rate for Payer: Cigna of CA HMO |
$69.94
|
| Rate for Payer: Cigna of CA PPO |
$69.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$84.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.97
|
| Rate for Payer: EPIC Health Plan Transplant |
$39.97
|
| Rate for Payer: Galaxy Health WC |
$84.93
|
| Rate for Payer: Global Benefits Group Commercial |
$59.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$89.93
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$74.94
|
| Rate for Payer: IEHP medi-cal |
$34.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$66.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.98
|
| Rate for Payer: Multiplan Commercial |
$74.94
|
| Rate for Payer: Networks By Design Commercial |
$64.95
|
| Rate for Payer: Prime Health Services Commercial |
$84.93
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$59.95
|
| Rate for Payer: Riverside University Health MISP |
$39.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$59.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$59.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$49.96
|
| Rate for Payer: United Healthcare All Other HMO |
$49.96
|
| Rate for Payer: United Healthcare HMO Rider |
$49.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$49.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$84.93
|
| Rate for Payer: Vantage Medical Group Senior |
$84.93
|
|
|
SILDENAFIL ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080335]
|
Facility
IP
|
$2.81
|
|
|
Service Code
|
NDC 9994-0803-35
|
| Hospital Charge Code |
1715001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Cigna of CA PPO |
$1.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$2.11
|
| Rate for Payer: Blue Shield of California EPN |
$1.50
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Central Health Plan Commercial |
$2.25
|
| Rate for Payer: Cigna of CA HMO |
$1.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.39
|
| Rate for Payer: Global Benefits Group Commercial |
$1.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$2.11
|
| Rate for Payer: Networks By Design Commercial |
$1.83
|
| Rate for Payer: Prime Health Services Commercial |
$2.39
|
|
|
SILDENAFIL ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080335]
|
Facility
OP
|
$2.81
|
|
|
Service Code
|
NDC 9994-0803-35
|
| Hospital Charge Code |
1715001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.66
|
| Rate for Payer: BCBS Transplant Transplant |
$1.69
|
| Rate for Payer: Blue Shield of California Commercial |
$1.77
|
| Rate for Payer: Blue Shield of California EPN |
$1.37
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Central Health Plan Commercial |
$2.25
|
| Rate for Payer: Cigna of CA HMO |
$1.97
|
| Rate for Payer: Cigna of CA PPO |
$1.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.39
|
| Rate for Payer: Global Benefits Group Commercial |
$1.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.53
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.11
|
| Rate for Payer: IEHP medi-cal |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$2.11
|
| Rate for Payer: Networks By Design Commercial |
$1.83
|
| Rate for Payer: Prime Health Services Commercial |
$2.39
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.69
|
| Rate for Payer: Riverside University Health MISP |
$1.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.40
|
| Rate for Payer: United Healthcare All Other HMO |
$1.40
|
| Rate for Payer: United Healthcare HMO Rider |
$1.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.39
|
| Rate for Payer: Vantage Medical Group Senior |
$2.39
|
|
|
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]
|
Facility
IP
|
$1.40
|
|
|
Service Code
|
CPT S0090
|
| Hospital Charge Code |
1711956
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Central Health Plan Commercial |
$1.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.71
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Galaxy Health WC |
$0.76
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Prime Health Services Commercial |
$0.76
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
|
|
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]
|
Facility
OP
|
$0.89
|
|
|
Service Code
|
CPT S0090
|
| Hospital Charge Code |
1711956
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$56.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$51.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$51.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.44
|
| Rate for Payer: BCBS Transplant Transplant |
$0.53
|
| Rate for Payer: BCBS Transplant Transplant |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Central Health Plan Commercial |
$1.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.71
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.76
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.67
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.05
|
| Rate for Payer: IEHP medi-cal |
$0.49
|
| Rate for Payer: IEHP medi-cal |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Networks By Design Commercial |
$0.58
|
| Rate for Payer: Prime Health Services Commercial |
$0.76
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.53
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.84
|
| Rate for Payer: Riverside University Health MISP |
$0.56
|
| Rate for Payer: Riverside University Health MISP |
$0.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.70
|
| Rate for Payer: United Healthcare All Other HMO |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.70
|
| Rate for Payer: United Healthcare HMO Rider |
$0.45
|
| Rate for Payer: United Healthcare HMO Rider |
$0.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.76
|
|
|
SILTUXIMAB 100 MG INTRAVENOUS SOLUTION [205871]
|
Facility
OP
|
$1,703.24
|
|
|
Service Code
|
CPT J2860
|
| Hospital Charge Code |
ERX205871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$140.79 |
| Max. Negotiated Rate |
$1,532.92 |
| Rate for Payer: Adventist Health Medi-Cal |
$148.94
|
| Rate for Payer: Aetna of CA HMO/PPO |
$922.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$186.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$163.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$163.84
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$169.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$185.95
|
| Rate for Payer: BCBS Transplant Transplant |
$1,021.94
|
| Rate for Payer: Blue Shield of California Commercial |
$154.87
|
| Rate for Payer: Blue Shield of California EPN |
$140.79
|
| Rate for Payer: Caremore Medicare Advantage |
$148.94
|
| Rate for Payer: Cash Price |
$766.46
|
| Rate for Payer: Cash Price |
$766.46
|
| Rate for Payer: Central Health Plan Commercial |
$1,362.59
|
| Rate for Payer: Cigna of CA HMO |
$1,192.27
|
| Rate for Payer: Cigna of CA PPO |
$1,192.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$223.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$201.07
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$148.94
|
| Rate for Payer: EPIC Health Plan Transplant |
$148.94
|
| Rate for Payer: Galaxy Health WC |
$1,447.75
|
| Rate for Payer: Global Benefits Group Commercial |
$1,021.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,532.92
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,277.43
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$244.27
|
| Rate for Payer: IEHP medi-cal |
$245.76
|
| Rate for Payer: IEHP Medicare Advantage |
$148.94
|
| Rate for Payer: Innovage PACE Commercial |
$223.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,136.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$148.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$340.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$199.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$199.58
|
| Rate for Payer: Multiplan Commercial |
$1,277.43
|
| Rate for Payer: Networks By Design Commercial |
$851.62
|
| Rate for Payer: Prime Health Services Commercial |
$1,447.75
|
| Rate for Payer: Prime Health Services Medicare |
$157.88
|
| Rate for Payer: Riverside University Health MISP |
$163.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,021.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,021.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$851.62
|
| Rate for Payer: United Healthcare All Other HMO |
$851.62
|
| Rate for Payer: United Healthcare HMO Rider |
$851.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$851.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$223.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$163.84
|
| Rate for Payer: Vantage Medical Group Senior |
$148.94
|
|
|
SILTUXIMAB 100 MG INTRAVENOUS SOLUTION [205871]
|
Facility
IP
|
$1,703.24
|
|
|
Service Code
|
CPT J2860
|
| Hospital Charge Code |
ERX205871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$340.65 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1,277.43
|
| Rate for Payer: Blue Shield of California EPN |
$909.53
|
| Rate for Payer: Cash Price |
$766.46
|
| Rate for Payer: Cash Price |
$766.46
|
| Rate for Payer: Central Health Plan Commercial |
$1,362.59
|
| Rate for Payer: Cigna of CA HMO |
$1,192.27
|
| Rate for Payer: Cigna of CA PPO |
$1,192.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$681.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$681.30
|
| Rate for Payer: Galaxy Health WC |
$1,447.75
|
| Rate for Payer: Global Benefits Group Commercial |
$1,021.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,532.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,136.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$340.65
|
| Rate for Payer: Multiplan Commercial |
$1,277.43
|
| Rate for Payer: Networks By Design Commercial |
$851.62
|
| Rate for Payer: Prime Health Services Commercial |
$1,447.75
|
|
|
SILTUXIMAB 400 MG INTRAVENOUS SOLUTION [205872]
|
Facility
IP
|
$6,812.98
|
|
|
Service Code
|
CPT J2860
|
| Hospital Charge Code |
ERX205872
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,362.60 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$5,109.74
|
| Rate for Payer: Blue Shield of California EPN |
$3,638.13
|
| Rate for Payer: Cash Price |
$3,065.84
|
| Rate for Payer: Cash Price |
$3,065.84
|
| Rate for Payer: Central Health Plan Commercial |
$5,450.38
|
| Rate for Payer: Cigna of CA HMO |
$4,769.09
|
| Rate for Payer: Cigna of CA PPO |
$4,769.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,725.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,725.19
|
| Rate for Payer: Galaxy Health WC |
$5,791.03
|
| Rate for Payer: Global Benefits Group Commercial |
$4,087.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$6,131.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,544.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,362.60
|
| Rate for Payer: Multiplan Commercial |
$5,109.74
|
| Rate for Payer: Networks By Design Commercial |
$3,406.49
|
| Rate for Payer: Prime Health Services Commercial |
$5,791.03
|
|
|
SILTUXIMAB 400 MG INTRAVENOUS SOLUTION [205872]
|
Facility
OP
|
$6,812.98
|
|
|
Service Code
|
CPT J2860
|
| Hospital Charge Code |
ERX205872
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$140.79 |
| Max. Negotiated Rate |
$6,131.68 |
| Rate for Payer: Adventist Health Medi-Cal |
$148.94
|
| Rate for Payer: Aetna of CA HMO/PPO |
$922.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$186.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$163.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$163.84
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$169.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$185.95
|
| Rate for Payer: BCBS Transplant Transplant |
$4,087.79
|
| Rate for Payer: Blue Shield of California Commercial |
$154.87
|
| Rate for Payer: Blue Shield of California EPN |
$140.79
|
| Rate for Payer: Caremore Medicare Advantage |
$148.94
|
| Rate for Payer: Cash Price |
$3,065.84
|
| Rate for Payer: Cash Price |
$3,065.84
|
| Rate for Payer: Central Health Plan Commercial |
$5,450.38
|
| Rate for Payer: Cigna of CA HMO |
$4,769.09
|
| Rate for Payer: Cigna of CA PPO |
$4,769.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$223.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$201.07
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$148.94
|
| Rate for Payer: EPIC Health Plan Transplant |
$148.94
|
| Rate for Payer: Galaxy Health WC |
$5,791.03
|
| Rate for Payer: Global Benefits Group Commercial |
$4,087.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$6,131.68
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5,109.74
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$244.27
|
| Rate for Payer: IEHP medi-cal |
$245.76
|
| Rate for Payer: IEHP Medicare Advantage |
$148.94
|
| Rate for Payer: Innovage PACE Commercial |
$223.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,544.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$148.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,362.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$199.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$199.58
|
| Rate for Payer: Multiplan Commercial |
$5,109.74
|
| Rate for Payer: Networks By Design Commercial |
$3,406.49
|
| Rate for Payer: Prime Health Services Commercial |
$5,791.03
|
| Rate for Payer: Prime Health Services Medicare |
$157.88
|
| Rate for Payer: Riverside University Health MISP |
$163.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4,087.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4,087.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,406.49
|
| Rate for Payer: United Healthcare All Other HMO |
$3,406.49
|
| Rate for Payer: United Healthcare HMO Rider |
$3,406.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,406.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$223.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$163.84
|
| Rate for Payer: Vantage Medical Group Senior |
$148.94
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]
|
Facility
IP
|
$0.69
|
|
|
Service Code
|
NDC 8019629660
|
| Hospital Charge Code |
1743694
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Central Health Plan Commercial |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]
|
Facility
OP
|
$0.69
|
|
|
Service Code
|
NDC 8327030909
|
| Hospital Charge Code |
1743694
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: BCBS Transplant Transplant |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Central Health Plan Commercial |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.62
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.52
|
| Rate for Payer: IEHP medi-cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.41
|
| Rate for Payer: Riverside University Health MISP |
$0.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO |
$0.35
|
| Rate for Payer: United Healthcare HMO Rider |
$0.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]
|
Facility
IP
|
$0.69
|
|
|
Service Code
|
NDC 8327030909
|
| Hospital Charge Code |
1743694
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Central Health Plan Commercial |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]
|
Facility
OP
|
$0.69
|
|
|
Service Code
|
NDC 8019629660
|
| Hospital Charge Code |
1743694
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: BCBS Transplant Transplant |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Central Health Plan Commercial |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.62
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.52
|
| Rate for Payer: IEHP medi-cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.41
|
| Rate for Payer: Riverside University Health MISP |
$0.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO |
$0.35
|
| Rate for Payer: United Healthcare HMO Rider |
$0.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]
|
Facility
IP
|
$0.84
|
|
|
Service Code
|
NDC 12870-0001-2
|
| Hospital Charge Code |
1772054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Central Health Plan Commercial |
$0.67
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]
|
Facility
OP
|
$0.91
|
|
|
Service Code
|
NDC 12870-0001-1
|
| Hospital Charge Code |
1772054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: BCBS Transplant Transplant |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Central Health Plan Commercial |
$0.73
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.82
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.68
|
| Rate for Payer: IEHP medi-cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: Riverside University Health MISP |
$0.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]
|
Facility
OP
|
$0.84
|
|
|
Service Code
|
NDC 12870-0001-2
|
| Hospital Charge Code |
1772054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: BCBS Transplant Transplant |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Central Health Plan Commercial |
$0.67
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.76
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.63
|
| Rate for Payer: IEHP medi-cal |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: Riverside University Health MISP |
$0.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]
|
Facility
IP
|
$0.91
|
|
|
Service Code
|
NDC 12870-0001-1
|
| Hospital Charge Code |
1772054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Central Health Plan Commercial |
$0.73
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
IP
|
$0.29
|
|
|
Service Code
|
NDC 67877-124-05
|
| Hospital Charge Code |
1743179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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 |
$0.13
|
| Rate for Payer: Cash Price |
$0.13
|
| 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: 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: 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
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
IP
|
$0.29
|
|
|
Service Code
|
NDC 67877-124-50
|
| Hospital Charge Code |
1743179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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 |
$0.13
|
| Rate for Payer: Cash Price |
$0.13
|
| 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: 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: 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
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
IP
|
$0.30
|
|
|
Service Code
|
NDC 61570-131-55
|
| Hospital Charge Code |
1743179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 67877-124-25
|
| Hospital Charge Code |
1743588
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
|
|
