|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE [216968]
|
Facility
|
IP
|
$2,568.38
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$464.88 |
| Max. Negotiated Rate |
$1,926.29 |
| Rate for Payer: Adventist Health Commercial |
$513.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,654.04
|
| Rate for Payer: Cash Price |
$1,155.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,181.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,386.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,189.16
|
| Rate for Payer: Heritage Provider Network Senior |
$1,189.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$464.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$642.10
|
| Rate for Payer: Multiplan Commercial |
$1,926.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$927.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$850.39
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE [216968]
|
Facility
|
OP
|
$2,568.38
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$464.88 |
| Max. Negotiated Rate |
$2,183.12 |
| Rate for Payer: Adventist Health Commercial |
$513.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,587.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,183.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,412.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,926.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,284.70
|
| Rate for Payer: Blue Shield of California Commercial |
$1,566.71
|
| Rate for Payer: Blue Shield of California EPN |
$1,253.37
|
| Rate for Payer: Cash Price |
$1,155.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,181.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,183.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,183.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,183.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,643.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,189.16
|
| Rate for Payer: Heritage Provider Network Senior |
$1,189.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,225.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$464.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$642.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,797.87
|
| Rate for Payer: Multiplan Commercial |
$1,926.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,027.35
|
| Rate for Payer: TriValley Medical Group Senior |
$1,027.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$927.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$850.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,183.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,183.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2,183.12
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
NDC 4285815014
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$9.69 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.70
|
| Rate for Payer: Blue Shield of California Commercial |
$6.95
|
| Rate for Payer: Blue Shield of California EPN |
$5.56
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.06
|
| Rate for Payer: Heritage Provider Network Senior |
$7.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.56
|
| Rate for Payer: TriValley Medical Group Senior |
$4.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Vantage Medical Group Senior |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
NDC 4285815014
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.34
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.72
|
| Rate for Payer: Heritage Provider Network Senior |
$7.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$19.39
|
|
|
Service Code
|
NDC 0378647099
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$16.48 |
| Rate for Payer: Adventist Health Commercial |
$3.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.70
|
| Rate for Payer: Blue Shield of California Commercial |
$11.83
|
| Rate for Payer: Blue Shield of California EPN |
$9.46
|
| Rate for Payer: Cash Price |
$8.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.00
|
| Rate for Payer: Heritage Provider Network Senior |
$12.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$9.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13.57
|
| Rate for Payer: Multiplan Commercial |
$14.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.76
|
| Rate for Payer: TriValley Medical Group Senior |
$7.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.48
|
| Rate for Payer: Vantage Medical Group Senior |
$16.48
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$22.06
|
|
|
Service Code
|
NDC 0378647016
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.03
|
| Rate for Payer: Blue Shield of California Commercial |
$13.46
|
| Rate for Payer: Blue Shield of California EPN |
$10.77
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.66
|
| Rate for Payer: Heritage Provider Network Senior |
$13.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$10.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15.44
|
| Rate for Payer: Multiplan Commercial |
$16.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.82
|
| Rate for Payer: TriValley Medical Group Senior |
$8.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.75
|
| Rate for Payer: Vantage Medical Group Senior |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
NDC 4580258084
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$9.69 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.70
|
| Rate for Payer: Blue Shield of California Commercial |
$6.95
|
| Rate for Payer: Blue Shield of California EPN |
$5.56
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.06
|
| Rate for Payer: Heritage Provider Network Senior |
$7.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.56
|
| Rate for Payer: TriValley Medical Group Senior |
$4.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Vantage Medical Group Senior |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$8.54
|
|
|
Service Code
|
NDC 6923816622
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$7.26 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.27
|
| Rate for Payer: Blue Shield of California Commercial |
$5.21
|
| Rate for Payer: Blue Shield of California EPN |
$4.17
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.29
|
| Rate for Payer: Heritage Provider Network Senior |
$5.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.98
|
| Rate for Payer: Multiplan Commercial |
$6.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.42
|
| Rate for Payer: TriValley Medical Group Senior |
$3.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Vantage Medical Group Senior |
$7.26
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$8.54
|
|
|
Service Code
|
NDC 6923816621
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$7.26 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.27
|
| Rate for Payer: Blue Shield of California Commercial |
$5.21
|
| Rate for Payer: Blue Shield of California EPN |
$4.17
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.29
|
| Rate for Payer: Heritage Provider Network Senior |
$5.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.98
|
| Rate for Payer: Multiplan Commercial |
$6.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.42
|
| Rate for Payer: TriValley Medical Group Senior |
$3.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Vantage Medical Group Senior |
$7.26
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$19.39
|
|
|
Service Code
|
NDC 0378647099
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$14.54 |
| Rate for Payer: Adventist Health Commercial |
$3.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.49
|
| Rate for Payer: Cash Price |
$8.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.13
|
| Rate for Payer: Heritage Provider Network Senior |
$13.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.85
|
| Rate for Payer: Multiplan Commercial |
$14.54
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
NDC 4285815091
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.34
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.72
|
| Rate for Payer: Heritage Provider Network Senior |
$7.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$8.54
|
|
|
Service Code
|
NDC 6923816622
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$6.41 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.50
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.78
|
| Rate for Payer: Heritage Provider Network Senior |
$5.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.13
|
| Rate for Payer: Multiplan Commercial |
$6.41
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$8.54
|
|
|
Service Code
|
NDC 6923816621
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$6.41 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.50
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.78
|
| Rate for Payer: Heritage Provider Network Senior |
$5.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.13
|
| Rate for Payer: Multiplan Commercial |
$6.41
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
NDC 4580258001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.34
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.72
|
| Rate for Payer: Heritage Provider Network Senior |
$7.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
NDC 4580258084
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.34
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.72
|
| Rate for Payer: Heritage Provider Network Senior |
$7.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
NDC 4285815091
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$9.69 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.70
|
| Rate for Payer: Blue Shield of California Commercial |
$6.95
|
| Rate for Payer: Blue Shield of California EPN |
$5.56
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.06
|
| Rate for Payer: Heritage Provider Network Senior |
$7.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.56
|
| Rate for Payer: TriValley Medical Group Senior |
$4.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Vantage Medical Group Senior |
$9.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$22.06
|
|
|
Service Code
|
NDC 0378647097
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.03
|
| Rate for Payer: Blue Shield of California Commercial |
$13.46
|
| Rate for Payer: Blue Shield of California EPN |
$10.77
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.66
|
| Rate for Payer: Heritage Provider Network Senior |
$13.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$10.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15.44
|
| Rate for Payer: Multiplan Commercial |
$16.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.82
|
| Rate for Payer: TriValley Medical Group Senior |
$8.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.75
|
| Rate for Payer: Vantage Medical Group Senior |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$22.06
|
|
|
Service Code
|
NDC 0378647016
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$16.55 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.21
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.93
|
| Rate for Payer: Heritage Provider Network Senior |
$14.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.51
|
| Rate for Payer: Multiplan Commercial |
$16.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
IP
|
$22.06
|
|
|
Service Code
|
NDC 0378647097
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$16.55 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.21
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.93
|
| Rate for Payer: Heritage Provider Network Senior |
$14.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.51
|
| Rate for Payer: Multiplan Commercial |
$16.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
NDC 4580258001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$9.69 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.70
|
| Rate for Payer: Blue Shield of California Commercial |
$6.95
|
| Rate for Payer: Blue Shield of California EPN |
$5.56
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.06
|
| Rate for Payer: Heritage Provider Network Senior |
$7.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.56
|
| Rate for Payer: TriValley Medical Group Senior |
$4.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Vantage Medical Group Senior |
$9.69
|
|
|
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 13160
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,984.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,013.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,557.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,013.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,557.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,557.82
|
| Rate for Payer: Heritage Provider Network Senior |
$5,606.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,557.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8,659.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,241.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6,107.48
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,013.60
|
| Rate for Payer: TriValley Medical Group Senior |
$5,013.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,013.60
|
| Rate for Payer: Vantage Medical Group Senior |
$4,557.82
|
|
|
SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]
|
Facility
|
OP
|
$630.00
|
|
|
Service Code
|
HCPCS J2850
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.47 |
| Max. Negotiated Rate |
$472.50 |
| Rate for Payer: Adventist Health Commercial |
$126.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$389.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$53.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$47.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$51.38
|
| Rate for Payer: Blue Shield of California Commercial |
$33.47
|
| Rate for Payer: Blue Shield of California EPN |
$33.47
|
| Rate for Payer: Cash Price |
$283.50
|
| Rate for Payer: Cash Price |
$283.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$289.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$53.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$47.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$403.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$43.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$291.69
|
| Rate for Payer: Heritage Provider Network Senior |
$291.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$300.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$114.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$49.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$57.62
|
| Rate for Payer: Multiplan Commercial |
$472.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$252.00
|
| Rate for Payer: TriValley Medical Group Senior |
$252.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$227.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$208.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$53.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.30
|
| Rate for Payer: Vantage Medical Group Senior |
$47.30
|
|
|
SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]
|
Facility
|
IP
|
$630.00
|
|
|
Service Code
|
HCPCS J2850
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.03 |
| Max. Negotiated Rate |
$472.50 |
| Rate for Payer: Adventist Health Commercial |
$126.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$405.72
|
| Rate for Payer: Cash Price |
$283.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$289.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$340.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$291.69
|
| Rate for Payer: Heritage Provider Network Senior |
$291.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$114.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.50
|
| Rate for Payer: Multiplan Commercial |
$472.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$227.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$208.59
|
|
|
SECUKINUMAB 25 MG/ML INTRAVENOUS SOLUTION [239838]
|
Facility
|
IP
|
$538.72
|
|
|
Service Code
|
HCPCS J3247
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.51 |
| Max. Negotiated Rate |
$404.04 |
| Rate for Payer: Adventist Health Commercial |
$107.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$346.94
|
| Rate for Payer: Cash Price |
$242.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$247.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$290.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$249.43
|
| Rate for Payer: Heritage Provider Network Senior |
$249.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$97.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.68
|
| Rate for Payer: Multiplan Commercial |
$404.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$194.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$178.37
|
|
|
SECUKINUMAB 25 MG/ML INTRAVENOUS SOLUTION [239838]
|
Facility
|
OP
|
$538.72
|
|
|
Service Code
|
HCPCS J3247
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$404.04 |
| Rate for Payer: Adventist Health Commercial |
$107.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$332.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$41.01
|
| Rate for Payer: Blue Shield of California Commercial |
$17.43
|
| Rate for Payer: Blue Shield of California EPN |
$17.43
|
| Rate for Payer: Cash Price |
$242.42
|
| Rate for Payer: Cash Price |
$242.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$247.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$344.78
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$249.43
|
| Rate for Payer: Heritage Provider Network Senior |
$249.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$256.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$97.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$20.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24.43
|
| Rate for Payer: Multiplan Commercial |
$404.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$215.49
|
| Rate for Payer: TriValley Medical Group Senior |
$215.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$194.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$178.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.05
|
| Rate for Payer: Vantage Medical Group Senior |
$20.05
|
|
