|
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
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
HCPCS A9154
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
HCPCS A9154
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Senior |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
SARGRAMOSTIM 250 MCG SOLUTION FOR INJECTION [11338]
|
Facility
|
OP
|
$377.55
|
|
|
Service Code
|
HCPCS J2820
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.09 |
| Max. Negotiated Rate |
$283.16 |
| Rate for Payer: Adventist Health Commercial |
$75.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$201.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$259.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$70.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$61.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$159.78
|
| Rate for Payer: Blue Shield of California Commercial |
$62.93
|
| Rate for Payer: Blue Shield of California EPN |
$62.93
|
| Rate for Payer: Cash Price |
$207.65
|
| Rate for Payer: Cash Price |
$207.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$173.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$70.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.70
|
| Rate for Payer: Dignity Health Senior |
$61.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$241.63
|
| Rate for Payer: EPIC Health Plan Medicare |
$56.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$174.81
|
| Rate for Payer: Heritage Provider Network Senior |
$174.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$59.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$56.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$180.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$64.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$70.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$70.67
|
| Rate for Payer: Multiplan Commercial |
$283.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$151.02
|
| Rate for Payer: TriValley Medical Group Senior |
$151.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$136.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$125.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$70.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.70
|
| Rate for Payer: Vantage Medical Group Senior |
$61.70
|
|
|
SARGRAMOSTIM 250 MCG SOLUTION FOR INJECTION [11338]
|
Facility
|
IP
|
$377.55
|
|
|
Service Code
|
HCPCS J2820
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$68.34 |
| Max. Negotiated Rate |
$283.16 |
| Rate for Payer: Adventist Health Commercial |
$75.51
|
| Rate for Payer: Cash Price |
$207.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$173.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$203.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$174.81
|
| Rate for Payer: Heritage Provider Network Senior |
$174.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.39
|
| Rate for Payer: Multiplan Commercial |
$283.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$136.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$125.01
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$16.55 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Cash Price |
$12.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.93
|
| Rate for Payer: Heritage Provider Network Senior |
$14.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.51
|
| Rate for Payer: Multiplan Commercial |
$16.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-97
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.55
|
| Rate for Payer: Blue Shield of California Commercial |
$13.46
|
| Rate for Payer: Blue Shield of California EPN |
$10.77
|
| Rate for Payer: Cash Price |
$12.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.75
|
| Rate for Payer: Dignity Health Senior |
$18.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.66
|
| Rate for Payer: Heritage Provider Network Senior |
$13.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.44
|
| Rate for Payer: Multiplan Commercial |
$16.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.82
|
| Rate for Payer: TriValley Medical Group Senior |
$8.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.75
|
| Rate for Payer: Vantage Medical Group Senior |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.55
|
| Rate for Payer: Blue Shield of California Commercial |
$13.46
|
| Rate for Payer: Blue Shield of California EPN |
$10.77
|
| Rate for Payer: Cash Price |
$12.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.75
|
| Rate for Payer: Dignity Health Senior |
$18.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.66
|
| Rate for Payer: Heritage Provider Network Senior |
$13.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.44
|
| Rate for Payer: Multiplan Commercial |
$16.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.82
|
| Rate for Payer: TriValley Medical Group Senior |
$8.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.75
|
| Rate for Payer: Vantage Medical Group Senior |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$19.39
|
|
|
Service Code
|
NDC 0378-6470-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$14.54 |
| Rate for Payer: Adventist Health Commercial |
$3.88
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.13
|
| Rate for Payer: Heritage Provider Network Senior |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.85
|
| Rate for Payer: Multiplan Commercial |
$14.54
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$19.39
|
|
|
Service Code
|
NDC 0378-6470-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$16.48 |
| Rate for Payer: Adventist Health Commercial |
$3.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.54
|
| Rate for Payer: Blue Shield of California Commercial |
$11.83
|
| Rate for Payer: Blue Shield of California EPN |
$9.46
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.48
|
| Rate for Payer: Dignity Health Senior |
$16.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.00
|
| Rate for Payer: Heritage Provider Network Senior |
$12.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.57
|
| Rate for Payer: Multiplan Commercial |
$14.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.76
|
| Rate for Payer: TriValley Medical Group Senior |
$7.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.48
|
| Rate for Payer: Vantage Medical Group Senior |
$16.48
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
NDC 42858-150-91
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.72
|
| Rate for Payer: Heritage Provider Network Senior |
$7.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
NDC 45802-580-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.72
|
| Rate for Payer: Heritage Provider Network Senior |
$7.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
NDC 45802-580-84
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$9.69 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Blue Shield of California Commercial |
$6.95
|
| Rate for Payer: Blue Shield of California EPN |
$5.56
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.69
|
| Rate for Payer: Dignity Health Senior |
$9.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.06
|
| Rate for Payer: Heritage Provider Network Senior |
$7.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.56
|
| Rate for Payer: TriValley Medical Group Senior |
$4.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Vantage Medical Group Senior |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
NDC 45802-580-84
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.72
|
| Rate for Payer: Heritage Provider Network Senior |
$7.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
NDC 45802-580-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$9.69 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Blue Shield of California Commercial |
$6.95
|
| Rate for Payer: Blue Shield of California EPN |
$5.56
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.69
|
| Rate for Payer: Dignity Health Senior |
$9.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.06
|
| Rate for Payer: Heritage Provider Network Senior |
$7.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.56
|
| Rate for Payer: TriValley Medical Group Senior |
$4.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Vantage Medical Group Senior |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
NDC 42858-150-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$9.69 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Blue Shield of California Commercial |
$6.95
|
| Rate for Payer: Blue Shield of California EPN |
$5.56
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.69
|
| Rate for Payer: Dignity Health Senior |
$9.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.06
|
| Rate for Payer: Heritage Provider Network Senior |
$7.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.56
|
| Rate for Payer: TriValley Medical Group Senior |
$4.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Vantage Medical Group Senior |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
NDC 42858-150-91
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$9.69 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Blue Shield of California Commercial |
$6.95
|
| Rate for Payer: Blue Shield of California EPN |
$5.56
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.69
|
| Rate for Payer: Dignity Health Senior |
$9.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.06
|
| Rate for Payer: Heritage Provider Network Senior |
$7.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.56
|
| Rate for Payer: TriValley Medical Group Senior |
$4.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Vantage Medical Group Senior |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-97
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$16.55 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Cash Price |
$12.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.93
|
| Rate for Payer: Heritage Provider Network Senior |
$14.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.51
|
| Rate for Payer: Multiplan Commercial |
$16.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
NDC 42858-150-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.72
|
| Rate for Payer: Heritage Provider Network Senior |
$7.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
|
|
SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]
|
Facility
|
OP
|
$630.00
|
|
|
Service Code
|
HCPCS J2850
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.47 |
| Max. Negotiated Rate |
$472.50 |
| Rate for Payer: Adventist Health Commercial |
$126.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$336.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$432.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$48.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$48.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$107.01
|
| Rate for Payer: Blue Shield of California Commercial |
$33.47
|
| Rate for Payer: Blue Shield of California EPN |
$33.47
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$289.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.17
|
| Rate for Payer: Dignity Health Senior |
$48.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$403.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$43.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$291.69
|
| Rate for Payer: Heritage Provider Network Senior |
$291.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$60.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$300.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$114.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$50.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$55.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$55.18
|
| Rate for Payer: Multiplan Commercial |
$472.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$252.00
|
| Rate for Payer: TriValley Medical Group Senior |
$252.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$227.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$208.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.17
|
| Rate for Payer: Vantage Medical Group Senior |
$48.17
|
|
|
SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]
|
Facility
|
IP
|
$630.00
|
|
|
Service Code
|
HCPCS J2850
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.03 |
| Max. Negotiated Rate |
$472.50 |
| Rate for Payer: Adventist Health Commercial |
$126.00
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$289.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$340.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$291.69
|
| Rate for Payer: Heritage Provider Network Senior |
$291.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$114.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.50
|
| Rate for Payer: Multiplan Commercial |
$472.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$227.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$208.59
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 60505-0055-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Senior |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 60505-0055-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Blue Shield of California Commercial |
$1.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.71
|
| Rate for Payer: Dignity Health Senior |
$1.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1.71
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 4009310196
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 7985401163
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
