|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
IP
|
$14.53
|
|
|
Service Code
|
NDC 0078077720
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$10.90 |
| Rate for Payer: Adventist Health Commercial |
$2.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.36
|
| Rate for Payer: Cash Price |
$6.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.84
|
| Rate for Payer: Heritage Provider Network Senior |
$9.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.63
|
| Rate for Payer: Multiplan Commercial |
$10.90
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
IP
|
$14.53
|
|
|
Service Code
|
NDC 0078077767
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$10.90 |
| Rate for Payer: Adventist Health Commercial |
$2.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.36
|
| Rate for Payer: Cash Price |
$6.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.84
|
| Rate for Payer: Heritage Provider Network Senior |
$9.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.63
|
| Rate for Payer: Multiplan Commercial |
$10.90
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
OP
|
$14.53
|
|
|
Service Code
|
NDC 0078077720
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.35
|
| Rate for Payer: Adventist Health Commercial |
$2.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.27
|
| Rate for Payer: Blue Shield of California Commercial |
$8.86
|
| Rate for Payer: Blue Shield of California EPN |
$7.09
|
| Rate for Payer: Cash Price |
$6.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.99
|
| Rate for Payer: Heritage Provider Network Senior |
$8.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.17
|
| Rate for Payer: Multiplan Commercial |
$10.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.81
|
| Rate for Payer: TriValley Medical Group Senior |
$5.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.35
|
| Rate for Payer: Vantage Medical Group Senior |
$12.35
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
IP
|
$1.24
|
|
|
Service Code
|
NDC 3334257109
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Senior |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 6233255760
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.06
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 6233255760
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Senior |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Vantage Medical Group Senior |
$1.39
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
NDC 3334257109
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
|
OP
|
$14.53
|
|
|
Service Code
|
NDC 0078077767
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Adventist Health Commercial |
$2.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.27
|
| Rate for Payer: Blue Shield of California Commercial |
$8.86
|
| Rate for Payer: Blue Shield of California EPN |
$7.09
|
| Rate for Payer: Cash Price |
$6.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.99
|
| Rate for Payer: Heritage Provider Network Senior |
$8.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.17
|
| Rate for Payer: Multiplan Commercial |
$10.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.81
|
| Rate for Payer: TriValley Medical Group Senior |
$5.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.35
|
| Rate for Payer: Vantage Medical Group Senior |
$12.35
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 7037703313
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.01
|
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Senior |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Vantage Medical Group Senior |
$1.39
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
IP
|
$14.53
|
|
|
Service Code
|
NDC 0078069620
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$10.90 |
| Rate for Payer: Adventist Health Commercial |
$2.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.36
|
| Rate for Payer: Cash Price |
$6.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.84
|
| Rate for Payer: Heritage Provider Network Senior |
$9.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.63
|
| Rate for Payer: Multiplan Commercial |
$10.90
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 6233255860
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.06
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
OP
|
$14.53
|
|
|
Service Code
|
NDC 0078069620
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Adventist Health Commercial |
$2.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.27
|
| Rate for Payer: Blue Shield of California Commercial |
$8.86
|
| Rate for Payer: Blue Shield of California EPN |
$7.09
|
| Rate for Payer: Cash Price |
$6.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.99
|
| Rate for Payer: Heritage Provider Network Senior |
$8.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.17
|
| Rate for Payer: Multiplan Commercial |
$10.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.81
|
| Rate for Payer: TriValley Medical Group Senior |
$5.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.35
|
| Rate for Payer: Vantage Medical Group Senior |
$12.35
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 7037703313
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.06
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
OP
|
$1.99
|
|
|
Service Code
|
NDC 6923827331
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Senior |
$1.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.39
|
| Rate for Payer: Multiplan Commercial |
$1.49
|
| 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 |
$1.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.69
|
| Rate for Payer: Vantage Medical Group Senior |
$1.69
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
IP
|
$1.99
|
|
|
Service Code
|
NDC 6923827331
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.28
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.49
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 6233255860
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$1.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Senior |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Vantage Medical Group Senior |
$1.39
|
|
|
SALICYLIC ACID 17 % TOPICAL LIQUID [11323]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 1101725220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
SALICYLIC ACID 17 % TOPICAL LIQUID [11323]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 1101725220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
SALIVARY GLAND PROCEDURES
|
Facility
|
IP
|
$19,676.35
|
|
|
Service Code
|
MSDRG 139
|
| Min. Negotiated Rate |
$14,683.84 |
| Max. Negotiated Rate |
$19,676.35 |
| Rate for Payer: EPIC Health Plan Medicare |
$14,683.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14,683.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16,886.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$19,676.35
|
|
|
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY [120000]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 4858200155
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY [120000]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 4858200155
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
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: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| 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 Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 4858251201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
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: Aetna of CA Non-Gatekeeper |
$243.14
|
| Rate for Payer: Cash Price |
$169.90
|
| 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 Foundation Hospitals 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
|
|
|
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 |
$62.47 |
| Max. Negotiated Rate |
$309.06 |
| Rate for Payer: Blue Shield of California EPN |
$62.93
|
| Rate for Payer: Adventist Health Commercial |
$75.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$233.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$78.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$68.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$68.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$309.06
|
| Rate for Payer: Blue Shield of California Commercial |
$62.93
|
| Rate for Payer: Cash Price |
$169.90
|
| Rate for Payer: Cash Price |
$169.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$173.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$78.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$68.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$241.63
|
| Rate for Payer: EPIC Health Plan Medicare |
$62.47
|
| 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) Medicare Advantage |
$62.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$180.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$68.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$71.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$83.71
|
| 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 |
$78.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.72
|
| Rate for Payer: Vantage Medical Group Senior |
$68.72
|
|
