|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
|
IP
|
$12.04
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$9.03 |
| Rate for Payer: Adventist Health Commercial |
$2.41
|
| Rate for Payer: Adventist Health Commercial |
$4.21
|
| Rate for Payer: Cash Price |
$11.58
|
| Rate for Payer: Cash Price |
$6.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.57
|
| Rate for Payer: Heritage Provider Network Senior |
$5.57
|
| Rate for Payer: Heritage Provider Network Senior |
$9.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.01
|
| Rate for Payer: Multiplan Commercial |
$15.79
|
| Rate for Payer: Multiplan Commercial |
$9.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.99
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
|
IP
|
$16.66
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$12.49 |
| Rate for Payer: Adventist Health Commercial |
$3.33
|
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$9.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.71
|
| Rate for Payer: Heritage Provider Network Senior |
$7.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.17
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$12.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.52
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
|
OP
|
$5.40
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$25.68 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Adventist Health Commercial |
$3.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.68
|
| Rate for Payer: Blue Shield of California Commercial |
$10.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10.00
|
| Rate for Payer: Blue Shield of California EPN |
$10.00
|
| Rate for Payer: Blue Shield of California EPN |
$10.00
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$9.16
|
| Rate for Payer: Cash Price |
$9.16
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.59
|
| Rate for Payer: Dignity Health Senior |
$14.16
|
| Rate for Payer: Dignity Health Senior |
$4.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.71
|
| Rate for Payer: Heritage Provider Network Senior |
$7.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.78
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$12.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.66
|
| Rate for Payer: TriValley Medical Group Senior |
$6.66
|
| Rate for Payer: TriValley Medical Group Senior |
$2.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$14.16
|
| Rate for Payer: Vantage Medical Group Senior |
$4.59
|
|
|
SITAGLIPTIN 100 MG TABLET [240314]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 70710-1901-3
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.95
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: Dignity Health Senior |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.98
|
| Rate for Payer: Heritage Provider Network Senior |
$1.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
SITAGLIPTIN 100 MG TABLET [240314]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 70710-1901-3
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.17
|
| Rate for Payer: Heritage Provider Network Senior |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006-0277-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006-0277-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006-0277-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Blue Shield of California Commercial |
$8.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Senior |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.28
|
| Rate for Payer: TriValley Medical Group Senior |
$5.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006-0277-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Blue Shield of California Commercial |
$8.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Senior |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.28
|
| Rate for Payer: TriValley Medical Group Senior |
$5.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006-0221-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Blue Shield of California Commercial |
$8.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Senior |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.28
|
| Rate for Payer: TriValley Medical Group Senior |
$5.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006-0221-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006-0112-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006-0112-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006-0112-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Blue Shield of California Commercial |
$8.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Senior |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.28
|
| Rate for Payer: TriValley Medical Group Senior |
$5.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006-0112-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Blue Shield of California Commercial |
$8.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Senior |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.28
|
| Rate for Payer: TriValley Medical Group Senior |
$5.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [7301]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 69784-231-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [7301]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 0409-7299-73
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [7301]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 0409-7299-73
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Senior |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Senior |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [7301]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 69784-231-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 63323-032-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 63323-032-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 63323-032-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 63323-032-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
SODIUM ACETATE ORAL SOLUTION (IV FORM) 2 MEQ/ML [4080443]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 9994-0804-43
|
| 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
|
|
|
SODIUM ACETATE ORAL SOLUTION (IV FORM) 2 MEQ/ML [4080443]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 9994-0804-43
|
| 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
|
|
