|
RUXOLITINIB 15 MG TABLET [153888]
|
Facility
|
IP
|
$352.00
|
|
|
Service Code
|
NDC 50881-015-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.71 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Adventist Health Commercial |
$70.40
|
| Rate for Payer: Cash Price |
$193.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$190.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$238.30
|
| Rate for Payer: Heritage Provider Network Senior |
$238.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.00
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
|
|
RUXOLITINIB 15 MG TABLET [153888]
|
Facility
|
OP
|
$352.00
|
|
|
Service Code
|
NDC 50881-015-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.71 |
| Max. Negotiated Rate |
$299.20 |
| Rate for Payer: Adventist Health Commercial |
$70.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$188.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$241.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$299.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$193.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$264.00
|
| Rate for Payer: Blue Shield of California Commercial |
$214.72
|
| Rate for Payer: Blue Shield of California EPN |
$171.78
|
| Rate for Payer: Cash Price |
$193.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$228.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$299.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$299.20
|
| Rate for Payer: Dignity Health Senior |
$299.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$225.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$217.89
|
| Rate for Payer: Heritage Provider Network Senior |
$217.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$167.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$246.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$246.40
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$140.80
|
| Rate for Payer: TriValley Medical Group Senior |
$140.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$176.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$176.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$299.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$299.20
|
| Rate for Payer: Vantage Medical Group Senior |
$299.20
|
|
|
RUXOLITINIB 20 MG TABLET [153889]
|
Facility
|
IP
|
$352.00
|
|
|
Service Code
|
NDC 50881-020-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.71 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Adventist Health Commercial |
$70.40
|
| Rate for Payer: Cash Price |
$193.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$190.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$238.30
|
| Rate for Payer: Heritage Provider Network Senior |
$238.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.00
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
|
|
RUXOLITINIB 20 MG TABLET [153889]
|
Facility
|
OP
|
$352.00
|
|
|
Service Code
|
NDC 50881-020-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.71 |
| Max. Negotiated Rate |
$299.20 |
| Rate for Payer: Adventist Health Commercial |
$70.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$188.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$241.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$299.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$193.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$264.00
|
| Rate for Payer: Blue Shield of California Commercial |
$214.72
|
| Rate for Payer: Blue Shield of California EPN |
$171.78
|
| Rate for Payer: Cash Price |
$193.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$228.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$299.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$299.20
|
| Rate for Payer: Dignity Health Senior |
$299.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$225.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$217.89
|
| Rate for Payer: Heritage Provider Network Senior |
$217.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$167.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$246.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$246.40
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$140.80
|
| Rate for Payer: TriValley Medical Group Senior |
$140.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$176.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$176.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$299.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$299.20
|
| Rate for Payer: Vantage Medical Group Senior |
$299.20
|
|
|
RUXOLITINIB 25 MG TABLET [153890]
|
Facility
|
IP
|
$352.00
|
|
|
Service Code
|
NDC 50881-025-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.71 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Adventist Health Commercial |
$70.40
|
| Rate for Payer: Cash Price |
$193.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$190.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$238.30
|
| Rate for Payer: Heritage Provider Network Senior |
$238.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.00
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
|
|
RUXOLITINIB 25 MG TABLET [153890]
|
Facility
|
OP
|
$352.00
|
|
|
Service Code
|
NDC 50881-025-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.71 |
| Max. Negotiated Rate |
$299.20 |
| Rate for Payer: Adventist Health Commercial |
$70.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$188.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$241.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$299.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$193.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$264.00
|
| Rate for Payer: Blue Shield of California Commercial |
$214.72
|
| Rate for Payer: Blue Shield of California EPN |
$171.78
|
| Rate for Payer: Cash Price |
$193.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$228.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$299.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$299.20
|
| Rate for Payer: Dignity Health Senior |
$299.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$225.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$217.89
|
| Rate for Payer: Heritage Provider Network Senior |
$217.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$167.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$246.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$246.40
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$140.80
|
| Rate for Payer: TriValley Medical Group Senior |
$140.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$176.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$176.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$299.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$299.20
|
| Rate for Payer: Vantage Medical Group Senior |
$299.20
|
|
|
RUXOLITINIB 5 MG TABLET [153886]
|
Facility
|
IP
|
$352.00
|
|
|
Service Code
|
NDC 50881-005-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.71 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Adventist Health Commercial |
$70.40
|
| Rate for Payer: Cash Price |
$193.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$190.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$238.30
|
| Rate for Payer: Heritage Provider Network Senior |
$238.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.00
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
|
|
RUXOLITINIB 5 MG TABLET [153886]
|
Facility
|
OP
|
$352.00
|
|
|
Service Code
|
NDC 50881-005-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.71 |
| Max. Negotiated Rate |
$299.20 |
| Rate for Payer: Adventist Health Commercial |
$70.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$188.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$241.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$299.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$193.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$264.00
|
| Rate for Payer: Blue Shield of California Commercial |
$214.72
|
| Rate for Payer: Blue Shield of California EPN |
$171.78
|
| Rate for Payer: Cash Price |
$193.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$228.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$299.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$299.20
|
| Rate for Payer: Dignity Health Senior |
$299.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$225.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$217.89
|
| Rate for Payer: Heritage Provider Network Senior |
$217.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$167.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$246.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$246.40
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$140.80
|
| Rate for Payer: TriValley Medical Group Senior |
$140.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$176.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$176.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$299.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$299.20
|
| Rate for Payer: Vantage Medical Group Senior |
$299.20
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
OP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0659-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$11.98 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.57
|
| Rate for Payer: Blue Shield of California Commercial |
$8.60
|
| Rate for Payer: Blue Shield of California EPN |
$6.88
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.98
|
| Rate for Payer: Dignity Health Senior |
$11.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.73
|
| Rate for Payer: Heritage Provider Network Senior |
$8.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.87
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.64
|
| Rate for Payer: TriValley Medical Group Senior |
$5.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.98
|
| Rate for Payer: Vantage Medical Group Senior |
$11.98
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 62332-556-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 62332-556-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.23
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.39
|
| Rate for Payer: Dignity Health Senior |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Senior |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Vantage Medical Group Senior |
$1.39
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
|
IP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0659-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$10.57 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.55
|
| Rate for Payer: Heritage Provider Network Senior |
$9.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.52
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
OP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0777-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$11.98 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.57
|
| Rate for Payer: Blue Shield of California Commercial |
$8.60
|
| Rate for Payer: Blue Shield of California EPN |
$6.88
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.98
|
| Rate for Payer: Dignity Health Senior |
$11.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.73
|
| Rate for Payer: Heritage Provider Network Senior |
$8.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.87
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.64
|
| Rate for Payer: TriValley Medical Group Senior |
$5.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.98
|
| Rate for Payer: Vantage Medical Group Senior |
$11.98
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
IP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0777-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$10.57 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.55
|
| Rate for Payer: Heritage Provider Network Senior |
$9.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.52
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
IP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0777-67
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$10.57 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.55
|
| Rate for Payer: Heritage Provider Network Senior |
$9.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.52
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 62332-557-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.23
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.39
|
| Rate for Payer: Dignity Health Senior |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Senior |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Vantage Medical Group Senior |
$1.39
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 62332-557-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
OP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0777-67
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$11.98 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.57
|
| Rate for Payer: Blue Shield of California Commercial |
$8.60
|
| Rate for Payer: Blue Shield of California EPN |
$6.88
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.98
|
| Rate for Payer: Dignity Health Senior |
$11.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.73
|
| Rate for Payer: Heritage Provider Network Senior |
$8.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.87
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.64
|
| Rate for Payer: TriValley Medical Group Senior |
$5.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.98
|
| Rate for Payer: Vantage Medical Group Senior |
$11.98
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
IP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0696-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$10.57 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.55
|
| Rate for Payer: Heritage Provider Network Senior |
$9.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.52
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
OP
|
$14.10
|
|
|
Service Code
|
NDC 0078-0696-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$11.98 |
| Rate for Payer: Adventist Health Commercial |
$2.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.57
|
| Rate for Payer: Blue Shield of California Commercial |
$8.60
|
| Rate for Payer: Blue Shield of California EPN |
$6.88
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.98
|
| Rate for Payer: Dignity Health Senior |
$11.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.73
|
| Rate for Payer: Heritage Provider Network Senior |
$8.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.87
|
| Rate for Payer: Multiplan Commercial |
$10.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.64
|
| Rate for Payer: TriValley Medical Group Senior |
$5.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.98
|
| Rate for Payer: Vantage Medical Group Senior |
$11.98
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 62332-558-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.23
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.39
|
| Rate for Payer: Dignity Health Senior |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Senior |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Vantage Medical Group Senior |
$1.39
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 62332-558-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
|
|
SALICYLIC ACID 17 % TOPICAL LIQUID [11323]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 1101725220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
SALICYLIC ACID 17 % TOPICAL LIQUID [11323]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 1101725220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Senior |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 4858251201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
