|
SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]
|
Facility
IP
|
$152.00
|
|
|
Service Code
|
CPT J2805
|
| Hospital Charge Code |
ERX11368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.40 |
| 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 |
$114.00
|
| Rate for Payer: Blue Shield of California EPN |
$81.17
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Central Health Plan Commercial |
$121.60
|
| Rate for Payer: Cigna of CA HMO |
$106.40
|
| Rate for Payer: Cigna of CA PPO |
$106.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$60.80
|
| Rate for Payer: Galaxy Health WC |
$129.20
|
| Rate for Payer: Global Benefits Group Commercial |
$91.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$136.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$101.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.40
|
| Rate for Payer: Multiplan Commercial |
$114.00
|
| Rate for Payer: Networks By Design Commercial |
$76.00
|
| Rate for Payer: Prime Health Services Commercial |
$129.20
|
|
|
SINUS AND MASTOID PROCEDURES AGE 0-17
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
TRIS-DRG 111
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
SINUS AND MASTOID PROCEDURES AGE >17 WITH CC/MCC
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
TRIS-DRG 135
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
SINUS AND MASTOID PROCEDURES AGE >17 WITHOUT CC/MCC
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
TRIS-DRG 136
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps
|
Facility
OP
|
$25,512.00
|
|
|
Service Code
|
CPT 31030
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,383.18 |
| Max. Negotiated Rate |
$25,512.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,316.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$10,003.24
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$7,316.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,877.82
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$7,316.90
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$11,999.72
|
| Rate for Payer: IEHP medi-cal |
$12,072.88
|
| Rate for Payer: IEHP Medicare Advantage |
$7,316.90
|
| Rate for Payer: Innovage PACE Commercial |
$10,975.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,316.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,804.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,804.65
|
| Rate for Payer: Multiplan WC |
$10,003.24
|
| Rate for Payer: Preferred Health Network WC |
$10,207.39
|
| Rate for Payer: Prime Health Services Medicare |
$7,755.91
|
| Rate for Payer: Prime Health Services WC |
$9,901.17
|
| Rate for Payer: Riverside University Health MISP |
$8,048.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$14,836.00
|
| Rate for Payer: United Healthcare All Other HMO |
$25,512.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,069.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14,692.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]
|
Facility
OP
|
$300.49
|
|
|
Service Code
|
CPT Q2043
|
| Hospital Charge Code |
1753491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.10 |
| Max. Negotiated Rate |
$331,088.02 |
| Rate for Payer: Adventist Health Medi-Cal |
$53,426.66
|
| Rate for Payer: Aetna of CA HMO/PPO |
$331,088.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$66,783.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$58,769.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$58,769.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$61,352.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$67,174.31
|
| Rate for Payer: BCBS Transplant Transplant |
$180.29
|
| Rate for Payer: Blue Shield of California Commercial |
$82,635.32
|
| Rate for Payer: Blue Shield of California EPN |
$75,123.02
|
| Rate for Payer: Caremore Medicare Advantage |
$53,426.66
|
| Rate for Payer: Cash Price |
$135.22
|
| Rate for Payer: Cash Price |
$135.22
|
| Rate for Payer: Central Health Plan Commercial |
$240.39
|
| Rate for Payer: Cigna of CA HMO |
$210.34
|
| Rate for Payer: Cigna of CA PPO |
$210.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$80,139.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$72,125.99
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$53,426.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$53,426.66
|
| Rate for Payer: Galaxy Health WC |
$255.42
|
| Rate for Payer: Global Benefits Group Commercial |
$180.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$270.44
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$225.37
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$87,619.72
|
| Rate for Payer: IEHP medi-cal |
$88,153.98
|
| Rate for Payer: IEHP Medicare Advantage |
$53,426.66
|
| Rate for Payer: Innovage PACE Commercial |
$80,139.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$200.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$53,426.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$71,591.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$71,591.72
|
| Rate for Payer: Multiplan Commercial |
$225.37
|
| Rate for Payer: Networks By Design Commercial |
$150.24
|
| Rate for Payer: Prime Health Services Commercial |
$255.42
|
| Rate for Payer: Prime Health Services Medicare |
$56,632.26
|
| Rate for Payer: Riverside University Health MISP |
$58,769.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$180.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$180.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$150.24
|
| Rate for Payer: United Healthcare All Other HMO |
$150.24
|
| Rate for Payer: United Healthcare HMO Rider |
$150.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$150.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$80,139.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$58,769.32
|
| Rate for Payer: Vantage Medical Group Senior |
$53,426.66
|
|
|
SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]
|
Facility
IP
|
$300.49
|
|
|
Service Code
|
CPT Q2043
|
| Hospital Charge Code |
1753491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.10 |
| 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 |
$225.37
|
| Rate for Payer: Blue Shield of California EPN |
$160.46
|
| Rate for Payer: Cash Price |
$135.22
|
| Rate for Payer: Cash Price |
$135.22
|
| Rate for Payer: Central Health Plan Commercial |
$240.39
|
| Rate for Payer: Cigna of CA HMO |
$210.34
|
| Rate for Payer: Cigna of CA PPO |
$210.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$120.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$120.20
|
| Rate for Payer: Galaxy Health WC |
$255.42
|
| Rate for Payer: Global Benefits Group Commercial |
$180.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$270.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$200.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.10
|
| Rate for Payer: Multiplan Commercial |
$225.37
|
| Rate for Payer: Networks By Design Commercial |
$150.24
|
| Rate for Payer: Prime Health Services Commercial |
$255.42
|
|
|
SIROLIMUS 0.5 MG TABLET [104764]
|
Facility
OP
|
$6.55
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1712518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.31 |
| 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: Aetna of CA HMO/PPO |
$16.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.69
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.35
|
| 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 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: Anthem Blue Cross of CA HMO/PPO |
$38.02
|
| Rate for Payer: BCBS Transplant Transplant |
$12.38
|
| Rate for Payer: BCBS Transplant Transplant |
$6.21
|
| Rate for Payer: BCBS Transplant Transplant |
$3.93
|
| 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 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: Blue Shield of California EPN |
$18.68
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Central Health Plan Commercial |
$5.24
|
| Rate for Payer: Central Health Plan Commercial |
$16.50
|
| Rate for Payer: Central Health Plan Commercial |
$8.28
|
| Rate for Payer: Cigna of CA HMO |
$7.24
|
| Rate for Payer: Cigna of CA HMO |
$4.58
|
| Rate for Payer: Cigna of CA HMO |
$14.44
|
| Rate for Payer: Cigna of CA PPO |
$4.58
|
| Rate for Payer: Cigna of CA PPO |
$14.44
|
| Rate for Payer: Cigna of CA PPO |
$7.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.25
|
| Rate for Payer: Galaxy Health WC |
$8.80
|
| Rate for Payer: Galaxy Health WC |
$17.54
|
| Rate for Payer: Galaxy Health WC |
$5.57
|
| Rate for Payer: Global Benefits Group Commercial |
$6.21
|
| Rate for Payer: Global Benefits Group Commercial |
$3.93
|
| Rate for Payer: Global Benefits Group Commercial |
$12.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$18.57
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$9.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$15.47
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.91
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$7.76
|
| Rate for Payer: IEHP medi-cal |
$1.34
|
| 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 |
$6.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.07
|
| Rate for Payer: Multiplan Commercial |
$4.91
|
| Rate for Payer: Multiplan Commercial |
$7.76
|
| Rate for Payer: Multiplan Commercial |
$15.47
|
| Rate for Payer: Networks By Design Commercial |
$5.18
|
| Rate for Payer: Networks By Design Commercial |
$10.32
|
| Rate for Payer: Networks By Design Commercial |
$3.28
|
| Rate for Payer: Prime Health Services Commercial |
$8.80
|
| Rate for Payer: Prime Health Services Commercial |
$17.54
|
| Rate for Payer: Prime Health Services Commercial |
$5.57
|
| Rate for Payer: Riverside University Health MISP |
$4.14
|
| Rate for Payer: Riverside University Health MISP |
$8.25
|
| Rate for Payer: Riverside University Health MISP |
$2.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.28
|
| Rate for Payer: United Healthcare All Other HMO |
$10.32
|
| Rate for Payer: United Healthcare All Other HMO |
$5.18
|
| Rate for Payer: United Healthcare All Other HMO |
$3.28
|
| Rate for Payer: United Healthcare HMO Rider |
$3.28
|
| Rate for Payer: United Healthcare HMO Rider |
$10.32
|
| Rate for Payer: United Healthcare HMO Rider |
$5.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.80
|
| Rate for Payer: Vantage Medical Group Senior |
$17.54
|
| Rate for Payer: Vantage Medical Group Senior |
$8.80
|
| Rate for Payer: Vantage Medical Group Senior |
$5.57
|
|
|
SIROLIMUS 0.5 MG TABLET [104764]
|
Facility
IP
|
$20.63
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1712518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.13 |
| 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: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$4.91
|
| Rate for Payer: Blue Shield of California Commercial |
$7.76
|
| Rate for Payer: Blue Shield of California Commercial |
$15.47
|
| Rate for Payer: Blue Shield of California EPN |
$11.02
|
| Rate for Payer: Blue Shield of California EPN |
$5.53
|
| Rate for Payer: Blue Shield of California EPN |
$3.50
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Central Health Plan Commercial |
$16.50
|
| Rate for Payer: Central Health Plan Commercial |
$8.28
|
| Rate for Payer: Central Health Plan Commercial |
$5.24
|
| Rate for Payer: Cigna of CA HMO |
$4.58
|
| Rate for Payer: Cigna of CA HMO |
$7.24
|
| Rate for Payer: Cigna of CA HMO |
$14.44
|
| Rate for Payer: Cigna of CA PPO |
$4.58
|
| Rate for Payer: Cigna of CA PPO |
$7.24
|
| Rate for Payer: Cigna of CA PPO |
$14.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.14
|
| Rate for Payer: Galaxy Health WC |
$17.54
|
| Rate for Payer: Galaxy Health WC |
$5.57
|
| Rate for Payer: Galaxy Health WC |
$8.80
|
| Rate for Payer: Global Benefits Group Commercial |
$3.93
|
| Rate for Payer: Global Benefits Group Commercial |
$12.38
|
| Rate for Payer: Global Benefits Group Commercial |
$6.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$9.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$18.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.07
|
| Rate for Payer: Multiplan Commercial |
$4.91
|
| Rate for Payer: Multiplan Commercial |
$15.47
|
| Rate for Payer: Multiplan Commercial |
$7.76
|
| Rate for Payer: Networks By Design Commercial |
$10.32
|
| Rate for Payer: Networks By Design Commercial |
$5.18
|
| Rate for Payer: Networks By Design Commercial |
$3.28
|
| Rate for Payer: Prime Health Services Commercial |
$5.57
|
| Rate for Payer: Prime Health Services Commercial |
$17.54
|
| Rate for Payer: Prime Health Services Commercial |
$8.80
|
|
|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
OP
|
$17.50
|
|
|
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 |
$17.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.58
|
| 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 |
$10.50
|
| Rate for Payer: BCBS Transplant Transplant |
$12.63
|
| 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 |
$9.47
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Central Health Plan Commercial |
$14.00
|
| Rate for Payer: Central Health Plan Commercial |
$16.84
|
| Rate for Payer: Cigna of CA HMO |
$14.74
|
| Rate for Payer: Cigna of CA HMO |
$12.25
|
| Rate for Payer: Cigna of CA PPO |
$14.74
|
| Rate for Payer: Cigna of CA PPO |
$12.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.00
|
| 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 |
$18.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.75
|
| 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 |
$11.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.04
|
| 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 |
$15.79
|
| Rate for Payer: Multiplan Commercial |
$13.12
|
| Rate for Payer: Networks By Design Commercial |
$8.75
|
| Rate for Payer: Networks By Design Commercial |
$10.52
|
| Rate for Payer: Prime Health Services Commercial |
$17.89
|
| Rate for Payer: Prime Health Services Commercial |
$14.88
|
| 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 |
$12.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.75
|
| 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 |
$10.52
|
| Rate for Payer: United Healthcare HMO Rider |
$8.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.89
|
| Rate for Payer: Vantage Medical Group Senior |
$14.88
|
| Rate for Payer: Vantage Medical Group Senior |
$17.89
|
|
|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
IP
|
$17.50
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1715200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.50 |
| 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 |
$15.79
|
| Rate for Payer: Blue Shield of California Commercial |
$13.12
|
| Rate for Payer: Blue Shield of California EPN |
$9.34
|
| Rate for Payer: Blue Shield of California EPN |
$11.24
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cash Price |
$7.88
|
| 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 |
$14.74
|
| Rate for Payer: Cigna of CA HMO |
$12.25
|
| Rate for Payer: Cigna of CA PPO |
$14.74
|
| Rate for Payer: Cigna of CA PPO |
$12.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.00
|
| Rate for Payer: Galaxy Health WC |
$14.88
|
| Rate for Payer: Galaxy Health WC |
$17.89
|
| Rate for Payer: Global Benefits Group Commercial |
$12.63
|
| Rate for Payer: Global Benefits Group Commercial |
$10.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$18.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.04
|
| 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 |
$15.79
|
| Rate for Payer: Multiplan Commercial |
$13.12
|
| Rate for Payer: Networks By Design Commercial |
$8.75
|
| Rate for Payer: Networks By Design Commercial |
$10.52
|
| Rate for Payer: Prime Health Services Commercial |
$14.88
|
| Rate for Payer: Prime Health Services Commercial |
$17.89
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
OP
|
$9.00
|
|
|
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 |
$14.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.95
|
| 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 |
$6.30
|
| Rate for Payer: Cigna of CA HMO |
$11.66
|
| Rate for Payer: Cigna of CA PPO |
$11.66
|
| Rate for Payer: Cigna of CA PPO |
$6.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.66
|
| Rate for Payer: Galaxy Health WC |
$7.65
|
| Rate for Payer: Galaxy Health WC |
$14.16
|
| Rate for Payer: Global Benefits Group Commercial |
$5.40
|
| Rate for Payer: Global Benefits Group Commercial |
$10.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.75
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$12.50
|
| 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 |
$8.33
|
| Rate for Payer: Networks By Design Commercial |
$4.50
|
| 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 |
$5.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$8.33
|
| 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 |
$4.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.33
|
| 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 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 |
$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 |
$6.75
|
| Rate for Payer: Blue Shield of California Commercial |
$12.50
|
| Rate for Payer: Blue Shield of California EPN |
$8.90
|
| Rate for Payer: Blue Shield of California EPN |
$4.81
|
| 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: 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 |
$5.40
|
| Rate for Payer: Global Benefits Group Commercial |
$10.00
|
| 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 |
$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 |
$8.33
|
| Rate for Payer: Networks By Design Commercial |
$4.50
|
| Rate for Payer: Prime Health Services Commercial |
$14.16
|
| Rate for Payer: Prime Health Services Commercial |
$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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 0006-0277-31
|
| 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 0006-0112-31
|
| 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
|
|
|
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 |
$34,005.88 |
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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: 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
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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
|
|
