|
SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]
|
Facility
|
IP
|
$300.49
|
|
|
Service Code
|
HCPCS Q2043
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.39 |
| Max. Negotiated Rate |
$225.37 |
| Rate for Payer: Adventist Health Commercial |
$60.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$193.52
|
| Rate for Payer: Cash Price |
$135.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$138.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$139.13
|
| Rate for Payer: Heritage Provider Network Senior |
$139.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$54.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.12
|
| Rate for Payer: Multiplan Commercial |
$225.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$108.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$99.49
|
|
|
SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]
|
Facility
|
OP
|
$300.49
|
|
|
Service Code
|
HCPCS Q2043
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.39 |
| Max. Negotiated Rate |
$83,898.65 |
| Rate for Payer: Adventist Health Commercial |
$60.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$185.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$83,898.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61,525.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$55,932.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75,149.25
|
| Rate for Payer: Blue Shield of California Commercial |
$66,147.00
|
| Rate for Payer: Blue Shield of California EPN |
$66,147.00
|
| Rate for Payer: Cash Price |
$135.22
|
| Rate for Payer: Cash Price |
$135.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$138.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69,915.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$61,525.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$61,525.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$192.31
|
| Rate for Payer: EPIC Health Plan Medicare |
$55,932.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$139.13
|
| Rate for Payer: Heritage Provider Network Senior |
$139.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$55,932.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$143.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$54.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$64,322.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$74,949.46
|
| Rate for Payer: Multiplan Commercial |
$225.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$120.20
|
| Rate for Payer: TriValley Medical Group Senior |
$120.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$108.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$99.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$69,915.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61,525.67
|
| Rate for Payer: Vantage Medical Group Senior |
$61,525.67
|
|
|
SIROLIMUS 0.5 MG TABLET [104764]
|
Facility
|
IP
|
$10.35
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Adventist Health Commercial |
$2.07
|
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$1.05
|
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.09
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$4.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$2.42
|
| Rate for Payer: Heritage Provider Network Senior |
$3.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.59
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
| Rate for Payer: Multiplan Commercial |
$4.91
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$7.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.17
|
|
|
SIROLIMUS 0.5 MG TABLET [104764]
|
Facility
|
OP
|
$5.23
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$42.54 |
| Rate for Payer: Adventist Health Commercial |
$1.05
|
| Rate for Payer: Adventist Health Commercial |
$2.07
|
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.54
|
| Rate for Payer: Blue Shield of California Commercial |
$10.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10.00
|
| Rate for Payer: Blue Shield of California EPN |
$10.00
|
| Rate for Payer: Blue Shield of California EPN |
$10.00
|
| Rate for Payer: Blue Shield of California EPN |
$10.00
|
| Rate for Payer: Blue Shield of California EPN |
$10.00
|
| Rate for Payer: Blue Shield of California EPN |
$10.00
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.42
|
| Rate for Payer: Heritage Provider Network Senior |
$2.42
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$4.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.58
|
| Rate for Payer: Multiplan Commercial |
$7.76
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$4.91
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.62
|
| Rate for Payer: TriValley Medical Group Senior |
$4.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.70
|
| Rate for Payer: TriValley Medical Group Senior |
$2.09
|
| Rate for Payer: TriValley Medical Group Senior |
$1.92
|
| Rate for Payer: TriValley Medical Group Senior |
$2.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.37
|
| 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: United Healthcare Navigate/Select/Select+ |
$1.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.80
|
| Rate for Payer: Vantage Medical Group Senior |
$5.57
|
| Rate for Payer: Vantage Medical Group Senior |
$8.80
|
| Rate for Payer: Vantage Medical Group Senior |
$4.45
|
| Rate for Payer: Vantage Medical Group Senior |
$1.48
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
|
|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
|
OP
|
$12.04
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$42.54 |
| Rate for Payer: Adventist Health Commercial |
$2.41
|
| Rate for Payer: Adventist Health Commercial |
$4.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.54
|
| Rate for Payer: Blue Shield of California Commercial |
$10.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10.00
|
| Rate for Payer: Blue Shield of California EPN |
$10.00
|
| Rate for Payer: Blue Shield of California EPN |
$10.00
|
| Rate for Payer: Cash Price |
$5.42
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cash Price |
$5.42
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$17.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.57
|
| Rate for Payer: Heritage Provider Network Senior |
$9.75
|
| Rate for Payer: Heritage Provider Network Senior |
$5.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$10.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$14.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.43
|
| Rate for Payer: Multiplan Commercial |
$15.79
|
| Rate for Payer: Multiplan Commercial |
$9.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.42
|
| Rate for Payer: TriValley Medical Group Senior |
$4.82
|
| Rate for Payer: TriValley Medical Group Senior |
$8.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.89
|
| Rate for Payer: Vantage Medical Group Senior |
$17.89
|
| Rate for Payer: Vantage Medical Group Senior |
$10.23
|
|
|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
|
IP
|
$12.04
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$9.03 |
| Rate for Payer: Adventist Health Commercial |
$2.41
|
| Rate for Payer: Adventist Health Commercial |
$4.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.56
|
| Rate for Payer: Cash Price |
$5.42
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.75
|
| Rate for Payer: Heritage Provider Network Senior |
$9.75
|
| Rate for Payer: Heritage Provider Network Senior |
$5.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.26
|
| Rate for Payer: Multiplan Commercial |
$9.03
|
| Rate for Payer: Multiplan Commercial |
$15.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.99
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
|
OP
|
$16.66
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$42.54 |
| Rate for Payer: Adventist Health Commercial |
$3.33
|
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.54
|
| Rate for Payer: Blue Shield of California Commercial |
$10.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10.00
|
| Rate for Payer: Blue Shield of California EPN |
$10.00
|
| Rate for Payer: Blue Shield of California EPN |
$10.00
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$7.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.66
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$12.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.16
|
| Rate for Payer: TriValley Medical Group Senior |
$6.66
|
| Rate for Payer: TriValley Medical Group Senior |
$2.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$14.16
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
|
IP
|
$16.66
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$12.49 |
| Rate for Payer: Adventist Health Commercial |
$3.33
|
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.48
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$7.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$12.49
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.52
|
|
|
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION [233123]
|
Facility
|
OP
|
$10,614.40
|
|
|
Service Code
|
HCPCS J9331
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.88 |
| Max. Negotiated Rate |
$7,960.80 |
| Rate for Payer: Adventist Health Commercial |
$2,122.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,559.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$136.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$100.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$91.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.51
|
| Rate for Payer: Blue Shield of California Commercial |
$77.88
|
| Rate for Payer: Blue Shield of California EPN |
$77.88
|
| Rate for Payer: Cash Price |
$4,776.48
|
| Rate for Payer: Cash Price |
$4,776.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,882.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$113.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$100.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$100.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,793.22
|
| Rate for Payer: EPIC Health Plan Medicare |
$91.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,914.47
|
| Rate for Payer: Heritage Provider Network Senior |
$4,914.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$91.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,063.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,921.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$104.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,653.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$121.98
|
| Rate for Payer: Multiplan Commercial |
$7,960.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,245.76
|
| Rate for Payer: TriValley Medical Group Senior |
$4,245.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,834.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,514.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$113.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$100.13
|
| Rate for Payer: Vantage Medical Group Senior |
$100.13
|
|
|
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION [233123]
|
Facility
|
IP
|
$10,614.40
|
|
|
Service Code
|
HCPCS J9331
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,921.21 |
| Max. Negotiated Rate |
$7,960.80 |
| Rate for Payer: Adventist Health Commercial |
$2,122.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,835.67
|
| Rate for Payer: Cash Price |
$4,776.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,882.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,731.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,914.47
|
| Rate for Payer: Heritage Provider Network Senior |
$4,914.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,921.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,653.60
|
| Rate for Payer: Multiplan Commercial |
$7,960.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,834.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,514.43
|
|
|
SITAGLIPTIN 100 MG TABLET [240314]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 7071019013
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
SITAGLIPTIN 100 MG TABLET [240314]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 7071019013
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.77
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
SITAGLIPTIN 50 MG TABLET [240316]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 7071019003
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
SITAGLIPTIN 50 MG TABLET [240316]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 7071019003
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.77
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006027701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.50
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006027731
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.50
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006027701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.60
|
| Rate for Payer: Blue Shield of California Commercial |
$8.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.28
|
| Rate for Payer: TriValley Medical Group Senior |
$5.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006027731
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.60
|
| Rate for Payer: Blue Shield of California Commercial |
$8.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.28
|
| Rate for Payer: TriValley Medical Group Senior |
$5.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006022131
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.50
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006022131
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.60
|
| Rate for Payer: Blue Shield of California Commercial |
$8.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.28
|
| Rate for Payer: TriValley Medical Group Senior |
$5.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006011231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.50
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006011228
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.60
|
| Rate for Payer: Blue Shield of California Commercial |
$8.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.28
|
| Rate for Payer: TriValley Medical Group Senior |
$5.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 0006011228
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.50
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 0006011231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.60
|
| Rate for Payer: Blue Shield of California Commercial |
$8.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.28
|
| Rate for Payer: TriValley Medical Group Senior |
$5.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
SKIN DEBRIDEMENT WITH CC
|
Facility
|
IP
|
$26,644.64
|
|
|
Service Code
|
MSDRG 571
|
| Min. Negotiated Rate |
$19,884.06 |
| Max. Negotiated Rate |
$26,644.64 |
| Rate for Payer: EPIC Health Plan Medicare |
$19,884.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19,884.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22,866.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$26,644.64
|
|
