|
SEIZURES WITH MCC
|
Facility
|
IP
|
$30,442.07
|
|
|
Service Code
|
MSDRG 100
|
| Min. Negotiated Rate |
$22,717.96 |
| Max. Negotiated Rate |
$30,442.07 |
| Rate for Payer: EPIC Health Plan Medicare |
$22,717.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22,717.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$26,125.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$30,442.07
|
|
|
SEIZURES WITHOUT MCC
|
Facility
|
IP
|
$14,561.46
|
|
|
Service Code
|
MSDRG 101
|
| Min. Negotiated Rate |
$10,866.76 |
| Max. Negotiated Rate |
$14,561.46 |
| Rate for Payer: EPIC Health Plan Medicare |
$10,866.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10,866.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$12,496.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$14,561.46
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 6050500551
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.29
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Senior |
$1.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 6050500551
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Blue Shield of California Commercial |
$1.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.96
|
| 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 |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1.71
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 7431203201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA 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: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 7985401163
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| 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 Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 4009310196
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 Senior |
$0.05
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 7985401163
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA 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: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 7431203201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| 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 Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 4009310196
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| 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 Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
SELENIUM 50 MCG TABLET [7140]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 2689972174
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
SELENIUM 50 MCG TABLET [7140]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 2689972174
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]
|
Facility
|
OP
|
$41.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.45 |
| Max. Negotiated Rate |
$34.99 |
| Rate for Payer: Adventist Health Commercial |
$8.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$34.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$30.87
|
| Rate for Payer: Blue Shield of California Commercial |
$25.11
|
| Rate for Payer: Blue Shield of California EPN |
$20.09
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$34.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$34.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.06
|
| Rate for Payer: Heritage Provider Network Senior |
$19.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$19.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$28.81
|
| Rate for Payer: Multiplan Commercial |
$30.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.46
|
| Rate for Payer: TriValley Medical Group Senior |
$16.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$34.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.99
|
| Rate for Payer: Vantage Medical Group Senior |
$34.99
|
|
|
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]
|
Facility
|
IP
|
$41.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.45 |
| Max. Negotiated Rate |
$30.87 |
| Rate for Payer: Adventist Health Commercial |
$8.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.51
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.06
|
| Rate for Payer: Heritage Provider Network Senior |
$19.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.29
|
| Rate for Payer: Multiplan Commercial |
$30.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.63
|
|
|
SELENIUM SULFIDE 1 % SHAMPOO [38961]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0536199553
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
SELENIUM SULFIDE 1 % SHAMPOO [38961]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0536199553
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
SELENIUM SULFIDE 2.25 % SHAMPOO [40158]
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 4219215206
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Senior |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
|
|
SELENIUM SULFIDE 2.25 % SHAMPOO [40158]
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 4219215206
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.48
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
SELEXIPAG 200 MCG TABLET [212415]
|
Facility
|
OP
|
$311.57
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.39 |
| Max. Negotiated Rate |
$264.83 |
| Rate for Payer: Adventist Health Commercial |
$62.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$192.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$264.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$171.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$233.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$155.85
|
| Rate for Payer: Blue Shield of California Commercial |
$190.06
|
| Rate for Payer: Blue Shield of California EPN |
$152.05
|
| Rate for Payer: Cash Price |
$140.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$143.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$264.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$264.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$264.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$144.26
|
| Rate for Payer: Heritage Provider Network Senior |
$144.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$148.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$56.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$218.10
|
| Rate for Payer: Multiplan Commercial |
$233.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$124.63
|
| Rate for Payer: TriValley Medical Group Senior |
$124.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$112.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$103.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$264.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$264.83
|
| Rate for Payer: Vantage Medical Group Senior |
$264.83
|
|
|
SELEXIPAG 200 MCG TABLET [212415]
|
Facility
|
IP
|
$311.57
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.39 |
| Max. Negotiated Rate |
$233.68 |
| Rate for Payer: Adventist Health Commercial |
$62.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$200.65
|
| Rate for Payer: Cash Price |
$140.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$143.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$168.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$144.26
|
| Rate for Payer: Heritage Provider Network Senior |
$144.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$56.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.89
|
| Rate for Payer: Multiplan Commercial |
$233.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$112.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$103.16
|
|
|
SELEXIPAG 400 MCG TABLET [212416]
|
Facility
|
OP
|
$484.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.70 |
| Max. Negotiated Rate |
$411.86 |
| Rate for Payer: Adventist Health Commercial |
$96.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$299.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$411.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$266.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$363.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$242.37
|
| Rate for Payer: Blue Shield of California Commercial |
$295.57
|
| Rate for Payer: Blue Shield of California EPN |
$236.46
|
| Rate for Payer: Cash Price |
$218.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$222.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$411.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$411.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$411.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$310.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$224.34
|
| Rate for Payer: Heritage Provider Network Senior |
$224.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$231.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$87.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$121.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$339.18
|
| Rate for Payer: Multiplan Commercial |
$363.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$193.82
|
| Rate for Payer: TriValley Medical Group Senior |
$193.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$175.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$160.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$411.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$411.86
|
| Rate for Payer: Vantage Medical Group Senior |
$411.86
|
|
|
SELEXIPAG 400 MCG TABLET [212416]
|
Facility
|
IP
|
$484.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.70 |
| Max. Negotiated Rate |
$363.40 |
| Rate for Payer: Adventist Health Commercial |
$96.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$312.04
|
| Rate for Payer: Cash Price |
$218.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$222.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$261.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$224.34
|
| Rate for Payer: Heritage Provider Network Senior |
$224.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$87.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$121.14
|
| Rate for Payer: Multiplan Commercial |
$363.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$175.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$160.43
|
|
|
SELEXIPAG 800 MCG TABLET [212418]
|
Facility
|
OP
|
$484.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700030
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$87.70 |
| Max. Negotiated Rate |
$411.86 |
| Rate for Payer: Adventist Health Commercial |
$96.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$299.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$411.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$266.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$363.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$242.37
|
| Rate for Payer: Blue Shield of California Commercial |
$295.57
|
| Rate for Payer: Blue Shield of California EPN |
$236.46
|
| Rate for Payer: Cash Price |
$218.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$314.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$411.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$411.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$411.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$310.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$299.93
|
| Rate for Payer: Heritage Provider Network Senior |
$299.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$231.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$87.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$121.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$339.18
|
| Rate for Payer: Multiplan Commercial |
$363.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$193.82
|
| Rate for Payer: TriValley Medical Group Senior |
$193.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$242.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$242.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$411.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$411.86
|
| Rate for Payer: Vantage Medical Group Senior |
$411.86
|
|
|
SELEXIPAG 800 MCG TABLET [212418]
|
Facility
|
IP
|
$484.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700030
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$87.70 |
| Max. Negotiated Rate |
$363.40 |
| Rate for Payer: Adventist Health Commercial |
$96.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$312.04
|
| Rate for Payer: Cash Price |
$218.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$261.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$328.03
|
| Rate for Payer: Heritage Provider Network Senior |
$328.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$87.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$121.14
|
| Rate for Payer: Multiplan Commercial |
$363.40
|
|
|
SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP [117388]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0121072208
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA 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: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
