|
RUXOLITINIB 15 MG TABLET [153888]
|
Facility
OP
|
$333.72
|
|
|
Service Code
|
NDC 50881-015-60
|
| Hospital Charge Code |
ERX153888
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.40 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Adventist Health Commercial |
$66.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$178.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$183.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$250.29
|
| Rate for Payer: Blue Shield of California Commercial |
$207.24
|
| Rate for Payer: Blue Shield of California EPN |
$195.89
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$216.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$283.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$283.66
|
| Rate for Payer: Dignity Health Senior |
$283.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$213.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$206.57
|
| Rate for Payer: Heritage Provider Network Senior |
$206.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$160.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.43
|
| Rate for Payer: Multiplan Commercial |
$250.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$283.66
|
| Rate for Payer: Vantage Medical Group Senior |
$283.66
|
|
|
RUXOLITINIB 20 MG TABLET [153889]
|
Facility
OP
|
$333.72
|
|
|
Service Code
|
NDC 50881-020-60
|
| Hospital Charge Code |
ERX153889
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.40 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Adventist Health Commercial |
$66.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$178.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$183.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$250.29
|
| Rate for Payer: Blue Shield of California Commercial |
$207.24
|
| Rate for Payer: Blue Shield of California EPN |
$195.89
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$216.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$283.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$283.66
|
| Rate for Payer: Dignity Health Senior |
$283.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$213.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$206.57
|
| Rate for Payer: Heritage Provider Network Senior |
$206.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$160.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.43
|
| Rate for Payer: Multiplan Commercial |
$250.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$283.66
|
| Rate for Payer: Vantage Medical Group Senior |
$283.66
|
|
|
RUXOLITINIB 20 MG TABLET [153889]
|
Facility
IP
|
$333.72
|
|
|
Service Code
|
NDC 50881-020-60
|
| Hospital Charge Code |
ERX153889
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.40 |
| Max. Negotiated Rate |
$250.29 |
| Rate for Payer: Adventist Health Commercial |
$66.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.27
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$180.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$225.93
|
| Rate for Payer: Heritage Provider Network Senior |
$225.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.43
|
| Rate for Payer: Multiplan Commercial |
$250.29
|
|
|
RUXOLITINIB 25 MG TABLET [153890]
|
Facility
OP
|
$333.72
|
|
|
Service Code
|
NDC 50881-025-60
|
| Hospital Charge Code |
ERX153890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.40 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Adventist Health Commercial |
$66.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$178.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$183.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$250.29
|
| Rate for Payer: Blue Shield of California Commercial |
$207.24
|
| Rate for Payer: Blue Shield of California EPN |
$195.89
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$216.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$283.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$283.66
|
| Rate for Payer: Dignity Health Senior |
$283.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$213.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$206.57
|
| Rate for Payer: Heritage Provider Network Senior |
$206.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$160.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.43
|
| Rate for Payer: Multiplan Commercial |
$250.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$283.66
|
| Rate for Payer: Vantage Medical Group Senior |
$283.66
|
|
|
RUXOLITINIB 25 MG TABLET [153890]
|
Facility
IP
|
$333.72
|
|
|
Service Code
|
NDC 50881-025-60
|
| Hospital Charge Code |
ERX153890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.40 |
| Max. Negotiated Rate |
$250.29 |
| Rate for Payer: Adventist Health Commercial |
$66.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.27
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$180.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$225.93
|
| Rate for Payer: Heritage Provider Network Senior |
$225.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.43
|
| Rate for Payer: Multiplan Commercial |
$250.29
|
|
|
RUXOLITINIB 5 MG TABLET [153886]
|
Facility
IP
|
$333.72
|
|
|
Service Code
|
NDC 50881-005-60
|
| Hospital Charge Code |
ERX153886
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.40 |
| Max. Negotiated Rate |
$250.29 |
| Rate for Payer: Adventist Health Commercial |
$66.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.27
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$180.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$225.93
|
| Rate for Payer: Heritage Provider Network Senior |
$225.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.43
|
| Rate for Payer: Multiplan Commercial |
$250.29
|
|
|
RUXOLITINIB 5 MG TABLET [153886]
|
Facility
OP
|
$333.72
|
|
|
Service Code
|
NDC 50881-005-60
|
| Hospital Charge Code |
ERX153886
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.40 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Adventist Health Commercial |
$66.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$178.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$183.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$250.29
|
| Rate for Payer: Blue Shield of California Commercial |
$207.24
|
| Rate for Payer: Blue Shield of California EPN |
$195.89
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$216.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$283.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$283.66
|
| Rate for Payer: Dignity Health Senior |
$283.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$213.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$206.57
|
| Rate for Payer: Heritage Provider Network Senior |
$206.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$160.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.43
|
| Rate for Payer: Multiplan Commercial |
$250.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$283.66
|
| Rate for Payer: Vantage Medical Group Senior |
$283.66
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [227764]
|
Facility
IP
|
$2,814.28
|
|
|
Service Code
|
NDC 55135-132-01
|
| Hospital Charge Code |
ERX227764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$509.38 |
| Max. Negotiated Rate |
$2,110.71 |
| Rate for Payer: Adventist Health Commercial |
$562.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,933.41
|
| Rate for Payer: Cash Price |
$1,266.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,294.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,519.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,905.27
|
| Rate for Payer: Heritage Provider Network Senior |
$1,905.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$509.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$703.57
|
| Rate for Payer: Multiplan Commercial |
$2,110.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,026.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$940.25
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [227764]
|
Facility
OP
|
$2,814.28
|
|
|
Service Code
|
NDC 55135-132-01
|
| Hospital Charge Code |
ERX227764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$509.38 |
| Max. Negotiated Rate |
$2,392.14 |
| Rate for Payer: Adventist Health Commercial |
$562.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,504.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,933.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,392.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,547.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,110.71
|
| Rate for Payer: Blue Shield of California Commercial |
$1,747.67
|
| Rate for Payer: Blue Shield of California EPN |
$1,651.98
|
| Rate for Payer: Cash Price |
$1,266.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,294.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,392.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,392.14
|
| Rate for Payer: Dignity Health Senior |
$2,392.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,801.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,303.01
|
| Rate for Payer: Heritage Provider Network Senior |
$1,303.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,356.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$509.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$703.57
|
| Rate for Payer: Multiplan Commercial |
$2,110.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,026.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$940.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,392.14
|
| Rate for Payer: Vantage Medical Group Senior |
$2,392.14
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
IP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0659-20
|
| Hospital Charge Code |
ERX210397
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$10.02 |
| Rate for Payer: Adventist Health Commercial |
$2.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.18
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.04
|
| Rate for Payer: Heritage Provider Network Senior |
$9.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.34
|
| Rate for Payer: Multiplan Commercial |
$10.02
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]
|
Facility
OP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0659-20
|
| Hospital Charge Code |
ERX210397
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Adventist Health Commercial |
$2.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.02
|
| Rate for Payer: Blue Shield of California Commercial |
$8.30
|
| Rate for Payer: Blue Shield of California EPN |
$7.84
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.36
|
| Rate for Payer: Dignity Health Senior |
$11.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.27
|
| Rate for Payer: Heritage Provider Network Senior |
$8.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.34
|
| Rate for Payer: Multiplan Commercial |
$10.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.36
|
| Rate for Payer: Vantage Medical Group Senior |
$11.36
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
IP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0777-20
|
| Hospital Charge Code |
ERX210398
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$10.02 |
| Rate for Payer: Adventist Health Commercial |
$2.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.18
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.04
|
| Rate for Payer: Heritage Provider Network Senior |
$9.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.34
|
| Rate for Payer: Multiplan Commercial |
$10.02
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]
|
Facility
OP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0777-20
|
| Hospital Charge Code |
ERX210398
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Adventist Health Commercial |
$2.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.02
|
| Rate for Payer: Blue Shield of California Commercial |
$8.30
|
| Rate for Payer: Blue Shield of California EPN |
$7.84
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.36
|
| Rate for Payer: Dignity Health Senior |
$11.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.27
|
| Rate for Payer: Heritage Provider Network Senior |
$8.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.34
|
| Rate for Payer: Multiplan Commercial |
$10.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.36
|
| Rate for Payer: Vantage Medical Group Senior |
$11.36
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
IP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0696-20
|
| Hospital Charge Code |
ERX210399
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$10.02 |
| Rate for Payer: Adventist Health Commercial |
$2.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.18
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.04
|
| Rate for Payer: Heritage Provider Network Senior |
$9.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.34
|
| Rate for Payer: Multiplan Commercial |
$10.02
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]
|
Facility
OP
|
$13.36
|
|
|
Service Code
|
NDC 0078-0696-20
|
| Hospital Charge Code |
ERX210399
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Adventist Health Commercial |
$2.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.02
|
| Rate for Payer: Blue Shield of California Commercial |
$8.30
|
| Rate for Payer: Blue Shield of California EPN |
$7.84
|
| Rate for Payer: Cash Price |
$6.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.36
|
| Rate for Payer: Dignity Health Senior |
$11.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.27
|
| Rate for Payer: Heritage Provider Network Senior |
$8.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.34
|
| Rate for Payer: Multiplan Commercial |
$10.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.36
|
| Rate for Payer: Vantage Medical Group Senior |
$11.36
|
|
|
SALICYLIC ACID 17 % TOPICAL LIQUID [11323]
|
Facility
IP
|
$0.62
|
|
|
Service Code
|
NDC 1101725220
|
| Hospital Charge Code |
NDG11323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
SALICYLIC ACID 17 % TOPICAL LIQUID [11323]
|
Facility
OP
|
$0.62
|
|
|
Service Code
|
NDC 1101725220
|
| Hospital Charge Code |
NDG11323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Senior |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
NDC 4858251201
|
| Hospital Charge Code |
NDG216603
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]
|
Facility
OP
|
$0.14
|
|
|
Service Code
|
NDC 4858251201
|
| Hospital Charge Code |
NDG216603
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
OP
|
$0.33
|
|
|
Service Code
|
NDC 73090-0800-02
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Senior |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 6014629157
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 8489800001
|
| Hospital Charge Code |
1719220
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 8489800001
|
| Hospital Charge Code |
1719220
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 6014629157
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
SALIVA SUBSTITUTE COMBO NO.2 [117779]
|
Facility
IP
|
$0.33
|
|
|
Service Code
|
NDC 73090-0800-02
|
| Hospital Charge Code |
NDG117779A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
