|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 7431203201
|
| 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
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 7431203201
|
| 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: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| 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 Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
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
|
IP
|
$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: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| 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 Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
SELENIUM 50 MCG TABLET [7140]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 26899-721-74
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| 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 |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| 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 |
$0.04
|
| 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 |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
SELENIUM 50 MCG TABLET [7140]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 26899-721-74
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]
|
Facility
|
OP
|
$41.16
|
|
|
Service Code
|
NDC 0517-6560-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.45 |
| Max. Negotiated Rate |
$34.99 |
| Rate for Payer: Adventist Health Commercial |
$8.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$34.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$30.87
|
| Rate for Payer: Blue Shield of California Commercial |
$25.11
|
| Rate for Payer: Blue Shield of California EPN |
$20.09
|
| Rate for Payer: Cash Price |
$22.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$34.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.99
|
| Rate for Payer: Dignity Health Senior |
$34.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.48
|
| Rate for Payer: Heritage Provider Network Senior |
$25.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$19.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$28.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$28.81
|
| Rate for Payer: Multiplan Commercial |
$30.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.46
|
| Rate for Payer: TriValley Medical Group Senior |
$16.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$34.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.99
|
| Rate for Payer: Vantage Medical Group Senior |
$34.99
|
|
|
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]
|
Facility
|
IP
|
$41.16
|
|
|
Service Code
|
NDC 0517-6560-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.45 |
| Max. Negotiated Rate |
$30.87 |
| Rate for Payer: Adventist Health Commercial |
$8.23
|
| Rate for Payer: Cash Price |
$22.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.87
|
| Rate for Payer: Heritage Provider Network Senior |
$27.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.29
|
| Rate for Payer: Multiplan Commercial |
$30.87
|
|
|
SELENIUM SULFIDE 1 % SHAMPOO [38961]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0536-1995-53
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
SELENIUM SULFIDE 1 % SHAMPOO [38961]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0536-1995-53
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
SELENIUM SULFIDE 2.25 % SHAMPOO [40158]
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 42192-152-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Senior |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Senior |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
|
|
SELENIUM SULFIDE 2.25 % SHAMPOO [40158]
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 42192-152-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
SELEXIPAG 200 MCG TABLET [212415]
|
Facility
|
IP
|
$306.97
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.56 |
| Max. Negotiated Rate |
$230.23 |
| Rate for Payer: Adventist Health Commercial |
$61.39
|
| Rate for Payer: Cash Price |
$168.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$141.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$165.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$142.13
|
| Rate for Payer: Heritage Provider Network Senior |
$142.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.74
|
| Rate for Payer: Multiplan Commercial |
$230.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$110.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$101.64
|
|
|
SELEXIPAG 200 MCG TABLET [212415]
|
Facility
|
OP
|
$306.97
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.56 |
| Max. Negotiated Rate |
$260.92 |
| Rate for Payer: Adventist Health Commercial |
$61.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$164.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$210.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$260.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$168.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$230.23
|
| Rate for Payer: Blue Shield of California Commercial |
$187.25
|
| Rate for Payer: Blue Shield of California EPN |
$149.80
|
| Rate for Payer: Cash Price |
$168.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$141.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$260.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$260.92
|
| Rate for Payer: Dignity Health Senior |
$260.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$196.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$142.13
|
| Rate for Payer: Heritage Provider Network Senior |
$142.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$146.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$214.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$214.88
|
| Rate for Payer: Multiplan Commercial |
$230.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$122.79
|
| Rate for Payer: TriValley Medical Group Senior |
$122.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$110.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$101.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$260.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$260.92
|
| Rate for Payer: Vantage Medical Group Senior |
$260.92
|
|
|
SELEXIPAG 400 MCG TABLET [212416]
|
Facility
|
IP
|
$477.38
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.41 |
| Max. Negotiated Rate |
$358.04 |
| Rate for Payer: Adventist Health Commercial |
$95.48
|
| Rate for Payer: Cash Price |
$262.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$219.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$257.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$221.03
|
| Rate for Payer: Heritage Provider Network Senior |
$221.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.34
|
| Rate for Payer: Multiplan Commercial |
$358.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$172.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$158.06
|
|
|
SELEXIPAG 400 MCG TABLET [212416]
|
Facility
|
OP
|
$477.38
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.41 |
| Max. Negotiated Rate |
$405.77 |
| Rate for Payer: Adventist Health Commercial |
$95.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$255.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$327.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$405.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$262.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$358.04
|
| Rate for Payer: Blue Shield of California Commercial |
$291.20
|
| Rate for Payer: Blue Shield of California EPN |
$232.96
|
| Rate for Payer: Cash Price |
$262.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$219.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$405.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$405.77
|
| Rate for Payer: Dignity Health Senior |
$405.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$305.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$221.03
|
| Rate for Payer: Heritage Provider Network Senior |
$221.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$227.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$334.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$334.17
|
| Rate for Payer: Multiplan Commercial |
$358.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$190.95
|
| Rate for Payer: TriValley Medical Group Senior |
$190.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$172.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$158.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$405.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$405.77
|
| Rate for Payer: Vantage Medical Group Senior |
$405.77
|
|
|
SELEXIPAG 800 MCG TABLET [212418]
|
Facility
|
IP
|
$477.38
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700030
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$86.41 |
| Max. Negotiated Rate |
$358.04 |
| Rate for Payer: Adventist Health Commercial |
$95.48
|
| Rate for Payer: Cash Price |
$262.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$257.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$323.19
|
| Rate for Payer: Heritage Provider Network Senior |
$323.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.34
|
| Rate for Payer: Multiplan Commercial |
$358.04
|
|
|
SELEXIPAG 800 MCG TABLET [212418]
|
Facility
|
OP
|
$477.38
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700030
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$86.41 |
| Max. Negotiated Rate |
$405.77 |
| Rate for Payer: Adventist Health Commercial |
$95.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$255.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$327.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$405.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$262.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$358.04
|
| Rate for Payer: Blue Shield of California Commercial |
$291.20
|
| Rate for Payer: Blue Shield of California EPN |
$232.96
|
| Rate for Payer: Cash Price |
$262.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$310.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$405.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$405.77
|
| Rate for Payer: Dignity Health Senior |
$405.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$305.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$295.50
|
| Rate for Payer: Heritage Provider Network Senior |
$295.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$227.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$334.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$334.17
|
| Rate for Payer: Multiplan Commercial |
$358.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$190.95
|
| Rate for Payer: TriValley Medical Group Senior |
$190.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$238.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$238.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$405.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$405.77
|
| Rate for Payer: Vantage Medical Group Senior |
$405.77
|
|
|
SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP [117388]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0121072208
|
| 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: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| 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 Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP [117388]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0121072208
|
| 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
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 60687-622-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 0536-1248-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 69618-065-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 69618-065-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 67618-110-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| 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 |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| 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 |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
