|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$1.39
|
|
|
Service Code
|
NDC 5026872015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Senior |
$0.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$1.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.18
|
| Rate for Payer: Vantage Medical Group Senior |
$1.18
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$1.39
|
|
|
Service Code
|
NDC 5026872015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.94
|
| Rate for Payer: Heritage Provider Network Senior |
$0.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.04
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$3.46
|
|
|
Service Code
|
NDC 0904670706
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Adventist Health Commercial |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.23
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.34
|
| Rate for Payer: Heritage Provider Network Senior |
$2.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$2.60
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$3.46
|
|
|
Service Code
|
NDC 0904670706
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Adventist Health Commercial |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.73
|
| Rate for Payer: Blue Shield of California Commercial |
$2.11
|
| Rate for Payer: Blue Shield of California EPN |
$1.69
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Senior |
$2.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.42
|
| Rate for Payer: Multiplan Commercial |
$2.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.38
|
| Rate for Payer: TriValley Medical Group Senior |
$1.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.94
|
| Rate for Payer: Vantage Medical Group Senior |
$2.94
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 6586292127
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$2.28
|
|
|
Service Code
|
NDC 6809403459
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.47
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.71
|
|
|
SEVELAMER HCL 800 MG TABLET [28715]
|
Facility
|
OP
|
$3.33
|
|
|
Service Code
|
NDC 6846244718
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$2.03
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.33
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.33
|
| Rate for Payer: TriValley Medical Group Senior |
$1.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.83
|
| Rate for Payer: Vantage Medical Group Senior |
$2.83
|
|
|
SEVELAMER HCL 800 MG TABLET [28715]
|
Facility
|
IP
|
$3.33
|
|
|
Service Code
|
NDC 6846244718
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.14
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.10
|
|
|
SEVELAMER ORAL SUSPENSION COMPOUND 50 MG/ML [4080333]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 9994080333
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
SEVELAMER ORAL SUSPENSION COMPOUND 50 MG/ML [4080333]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 9994080333
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC
|
Facility
|
IP
|
$32,631.76
|
|
|
Service Code
|
MSDRG 511
|
| Min. Negotiated Rate |
$24,352.06 |
| Max. Negotiated Rate |
$32,631.76 |
| Rate for Payer: EPIC Health Plan Medicare |
$24,352.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24,352.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28,004.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32,631.76
|
|
|
SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC
|
Facility
|
IP
|
$47,082.80
|
|
|
Service Code
|
MSDRG 510
|
| Min. Negotiated Rate |
$35,136.42 |
| Max. Negotiated Rate |
$47,082.80 |
| Rate for Payer: EPIC Health Plan Medicare |
$35,136.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35,136.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$40,406.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$47,082.80
|
|
|
SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$26,121.04
|
|
|
Service Code
|
MSDRG 512
|
| Min. Negotiated Rate |
$19,493.31 |
| Max. Negotiated Rate |
$26,121.04 |
| Rate for Payer: EPIC Health Plan Medicare |
$19,493.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19,493.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22,417.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$26,121.04
|
|
|
SIALOLITHOTOMY; SUBMANDIBULAR (SUBMAXILLARY), COMPLICATED, INTRAORAL
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 42335
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,264.23 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,396.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,690.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,264.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| 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 |
$6,396.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,690.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,264.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,264.23
|
| Rate for Payer: Heritage Provider Network Senior |
$5,245.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,264.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8,102.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,903.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,714.07
|
| Rate for Payer: Multiplan WC |
$6,565.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,690.65
|
| Rate for Payer: TriValley Medical Group Senior |
$4,690.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,396.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,690.65
|
| Rate for Payer: Vantage Medical Group Senior |
$4,264.23
|
|
|
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC
|
Facility
|
IP
|
$20,998.44
|
|
|
Service Code
|
MSDRG 555
|
| Min. Negotiated Rate |
$15,670.48 |
| Max. Negotiated Rate |
$20,998.44 |
| Rate for Payer: EPIC Health Plan Medicare |
$15,670.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15,670.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,021.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20,998.44
|
|
|
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC
|
Facility
|
IP
|
$13,455.84
|
|
|
Service Code
|
MSDRG 556
|
| Min. Negotiated Rate |
$10,041.67 |
| Max. Negotiated Rate |
$13,455.84 |
| Rate for Payer: EPIC Health Plan Medicare |
$10,041.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10,041.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11,547.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13,455.84
|
|
|
SIGNS AND SYMPTOMS WITH MCC
|
Facility
|
IP
|
$20,193.83
|
|
|
Service Code
|
MSDRG 947
|
| Min. Negotiated Rate |
$15,070.02 |
| Max. Negotiated Rate |
$20,193.83 |
| Rate for Payer: EPIC Health Plan Medicare |
$15,070.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15,070.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17,330.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20,193.83
|
|
|
SIGNS AND SYMPTOMS WITHOUT MCC
|
Facility
|
IP
|
$12,993.66
|
|
|
Service Code
|
MSDRG 948
|
| Min. Negotiated Rate |
$9,696.76 |
| Max. Negotiated Rate |
$12,993.66 |
| Rate for Payer: EPIC Health Plan Medicare |
$9,696.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9,696.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11,151.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12,993.66
|
|
|
SILDENAFIL 10 MG/12.5 ML INTRAVENOUS SOLUTION [100417]
|
Facility
|
IP
|
$26.07
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.72 |
| Max. Negotiated Rate |
$19.55 |
| Rate for Payer: Adventist Health Commercial |
$5.21
|
| Rate for Payer: Adventist Health Commercial |
$3.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.79
|
| Rate for Payer: Cash Price |
$7.99
|
| Rate for Payer: Cash Price |
$11.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.07
|
| Rate for Payer: Heritage Provider Network Senior |
$12.07
|
| Rate for Payer: Heritage Provider Network Senior |
$8.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.52
|
| Rate for Payer: Multiplan Commercial |
$13.32
|
| Rate for Payer: Multiplan Commercial |
$19.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.88
|
|
|
SILDENAFIL 10 MG/12.5 ML INTRAVENOUS SOLUTION [100417]
|
Facility
|
OP
|
$17.76
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$15.10 |
| Rate for Payer: Adventist Health Commercial |
$3.55
|
| Rate for Payer: Adventist Health Commercial |
$5.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.32
|
| Rate for Payer: Blue Shield of California Commercial |
$10.83
|
| Rate for Payer: Blue Shield of California Commercial |
$15.90
|
| Rate for Payer: Blue Shield of California EPN |
$12.72
|
| Rate for Payer: Blue Shield of California EPN |
$8.67
|
| Rate for Payer: Cash Price |
$11.73
|
| Rate for Payer: Cash Price |
$7.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$22.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.07
|
| Rate for Payer: Heritage Provider Network Senior |
$8.22
|
| Rate for Payer: Heritage Provider Network Senior |
$12.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$12.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.43
|
| Rate for Payer: Multiplan Commercial |
$19.55
|
| Rate for Payer: Multiplan Commercial |
$13.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.43
|
| Rate for Payer: TriValley Medical Group Senior |
$7.10
|
| Rate for Payer: TriValley Medical Group Senior |
$10.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.16
|
| Rate for Payer: Vantage Medical Group Senior |
$22.16
|
| Rate for Payer: Vantage Medical Group Senior |
$15.10
|
|
|
SILDENAFIL 25 MG TABLET [22836]
|
Facility
|
OP
|
$104.91
|
|
|
Service Code
|
NDC 0069420030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.99 |
| Max. Negotiated Rate |
$89.17 |
| Rate for Payer: Adventist Health Commercial |
$20.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$64.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$57.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$78.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.48
|
| Rate for Payer: Blue Shield of California Commercial |
$64.00
|
| Rate for Payer: Blue Shield of California EPN |
$51.20
|
| Rate for Payer: Cash Price |
$47.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$68.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$89.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.94
|
| Rate for Payer: Heritage Provider Network Senior |
$64.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$50.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$73.44
|
| Rate for Payer: Multiplan Commercial |
$78.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$41.96
|
| Rate for Payer: TriValley Medical Group Senior |
$41.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$52.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$52.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.17
|
| Rate for Payer: Vantage Medical Group Senior |
$89.17
|
|
|
SILDENAFIL 25 MG TABLET [22836]
|
Facility
|
IP
|
$104.91
|
|
|
Service Code
|
NDC 0069420030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.99 |
| Max. Negotiated Rate |
$78.68 |
| Rate for Payer: Adventist Health Commercial |
$20.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$67.56
|
| Rate for Payer: Cash Price |
$47.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.02
|
| Rate for Payer: Heritage Provider Network Senior |
$71.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.23
|
| Rate for Payer: Multiplan Commercial |
$78.68
|
|
|
SILDENAFIL ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080335]
|
Facility
|
OP
|
$2.81
|
|
|
Service Code
|
NDC 9994080335
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.41
|
| Rate for Payer: Blue Shield of California Commercial |
$1.71
|
| Rate for Payer: Blue Shield of California EPN |
$1.37
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.74
|
| Rate for Payer: Heritage Provider Network Senior |
$1.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.97
|
| Rate for Payer: Multiplan Commercial |
$2.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.12
|
| Rate for Payer: TriValley Medical Group Senior |
$1.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.39
|
| Rate for Payer: Vantage Medical Group Senior |
$2.39
|
|
|
SILDENAFIL ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080335]
|
Facility
|
IP
|
$2.81
|
|
|
Service Code
|
NDC 9994080335
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.11 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.81
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.90
|
| Rate for Payer: Heritage Provider Network Senior |
$1.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$2.11
|
|
|
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
HCPCS S0090
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
