|
SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]
|
Facility
IP
|
$630.00
|
|
|
Service Code
|
CPT J2850
|
| Hospital Charge Code |
ERX91185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.03 |
| Max. Negotiated Rate |
$472.50 |
| Rate for Payer: Adventist Health Commercial |
$126.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$432.81
|
| Rate for Payer: Cash Price |
$283.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$289.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$340.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$426.51
|
| Rate for Payer: Heritage Provider Network Senior |
$426.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$114.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.50
|
| Rate for Payer: Multiplan Commercial |
$472.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$229.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$210.48
|
|
|
SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]
|
Facility
OP
|
$630.00
|
|
|
Service Code
|
CPT J2850
|
| Hospital Charge Code |
ERX91185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.47 |
| Max. Negotiated Rate |
$472.50 |
| Rate for Payer: Adventist Health Commercial |
$126.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$79.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$432.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$52.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$45.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$45.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$45.29
|
| Rate for Payer: Blue Shield of California Commercial |
$33.47
|
| Rate for Payer: Blue Shield of California EPN |
$33.47
|
| Rate for Payer: Cash Price |
$283.50
|
| Rate for Payer: Cash Price |
$283.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$289.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.91
|
| Rate for Payer: Dignity Health Senior |
$45.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$403.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$41.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$291.69
|
| Rate for Payer: Heritage Provider Network Senior |
$291.69
|
| Rate for Payer: Humana Medicare |
$41.74
|
| Rate for Payer: IEHP Medi-Cal |
$58.14
|
| Rate for Payer: IEHP Medicare Advantage |
$41.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$79.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$114.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$49.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$52.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$52.59
|
| Rate for Payer: Multiplan Commercial |
$472.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.91
|
| Rate for Payer: TriValley Medical Group Senior |
$41.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$229.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$210.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$62.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.91
|
| Rate for Payer: Vantage Medical Group Senior |
$41.74
|
|
|
SEIZURE
|
Facility
IP
|
$4,280.04
|
|
|
Service Code
|
APR-DRG 0531
|
| Min. Negotiated Rate |
$4,280.04 |
| Max. Negotiated Rate |
$4,280.04 |
| Rate for Payer: IEHP Medi-Cal |
$4,280.04
|
|
|
SEIZURE
|
Facility
IP
|
$5,458.99
|
|
|
Service Code
|
APR-DRG 0532
|
| Min. Negotiated Rate |
$5,458.99 |
| Max. Negotiated Rate |
$5,458.99 |
| Rate for Payer: IEHP Medi-Cal |
$5,458.99
|
|
|
SEIZURE
|
Facility
IP
|
$7,112.51
|
|
|
Service Code
|
APR-DRG 0533
|
| Min. Negotiated Rate |
$7,112.51 |
| Max. Negotiated Rate |
$7,112.51 |
| Rate for Payer: IEHP Medi-Cal |
$7,112.51
|
|
|
SEIZURE
|
Facility
IP
|
$16,183.97
|
|
|
Service Code
|
APR-DRG 0534
|
| Min. Negotiated Rate |
$16,183.97 |
| Max. Negotiated Rate |
$16,183.97 |
| Rate for Payer: IEHP Medi-Cal |
$16,183.97
|
|
|
Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 36245
|
| Min. Negotiated Rate |
$316.52 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$316.52
|
|
|
Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 36215
|
| Min. Negotiated Rate |
$281.10 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$6,699.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$281.10
|
|
|
Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 36246
|
| Min. Negotiated Rate |
$379.83 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$379.83
|
|
|
Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 36216
|
| Min. Negotiated Rate |
$68.53 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$6,699.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$68.53
|
|
|
Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 36247
|
| Min. Negotiated Rate |
$451.85 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$451.85
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
OP
|
$2.01
|
|
|
Service Code
|
NDC 60505-0055-1
|
| Hospital Charge Code |
1712623
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California EPN |
$1.18
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.71
|
| Rate for Payer: Dignity Health Senior |
$1.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1.71
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
IP
|
$2.01
|
|
|
Service Code
|
NDC 60505-0055-1
|
| Hospital Charge Code |
1712623
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.38
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Senior |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
IP
|
$0.06
|
|
|
Service Code
|
NDC 7985401163
|
| Hospital Charge Code |
ERX7139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
SELENIUM 200 MCG TABLET [7139]
|
Facility
OP
|
$0.06
|
|
|
Service Code
|
NDC 7985401163
|
| Hospital Charge Code |
ERX7139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
SELENIUM 50 MCG TABLET [7140]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 26899-721-74
|
| Hospital Charge Code |
1710887
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
SELENIUM 50 MCG TABLET [7140]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 26899-721-74
|
| Hospital Charge Code |
1710887
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]
|
Facility
OP
|
$41.16
|
|
|
Service Code
|
NDC 0517-6560-25
|
| Hospital Charge Code |
NDG225026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.45 |
| Max. Negotiated Rate |
$34.99 |
| Rate for Payer: Adventist Health Commercial |
$8.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$34.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$22.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$30.87
|
| Rate for Payer: Blue Shield of California Commercial |
$25.56
|
| Rate for Payer: Blue Shield of California EPN |
$24.16
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$34.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.99
|
| Rate for Payer: Dignity Health Senior |
$34.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.48
|
| Rate for Payer: Heritage Provider Network Senior |
$25.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$19.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.29
|
| Rate for Payer: Multiplan Commercial |
$30.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.99
|
| Rate for Payer: Vantage Medical Group Senior |
$34.99
|
|
|
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]
|
Facility
IP
|
$41.16
|
|
|
Service Code
|
NDC 0517-6560-25
|
| Hospital Charge Code |
NDG225026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.45 |
| Max. Negotiated Rate |
$30.87 |
| Rate for Payer: Adventist Health Commercial |
$8.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.28
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.87
|
| Rate for Payer: Heritage Provider Network Senior |
$27.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.29
|
| Rate for Payer: Multiplan Commercial |
$30.87
|
|
|
SELENIUM SULFIDE 1 % SHAMPOO [38961]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 0536-1995-53
|
| Hospital Charge Code |
1743730
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
SELENIUM SULFIDE 1 % SHAMPOO [38961]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 0536-1995-53
|
| Hospital Charge Code |
1743730
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
SELENIUM SULFIDE 2.25 % SHAMPOO [40158]
|
Facility
IP
|
$0.75
|
|
|
Service Code
|
NDC 42192-152-06
|
| Hospital Charge Code |
NDG40158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
SELENIUM SULFIDE 2.25 % SHAMPOO [40158]
|
Facility
OP
|
$0.75
|
|
|
Service Code
|
NDC 42192-152-06
|
| Hospital Charge Code |
NDG40158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Senior |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
|
|
SELEXIPAG 200 MCG TABLET [212415]
|
Facility
IP
|
$271.97
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
ERX212415
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.23 |
| Max. Negotiated Rate |
$203.98 |
| Rate for Payer: Adventist Health Commercial |
$54.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$186.84
|
| Rate for Payer: Cash Price |
$122.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$146.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$184.12
|
| Rate for Payer: Heritage Provider Network Senior |
$184.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.99
|
| Rate for Payer: Multiplan Commercial |
$203.98
|
|
|
SELEXIPAG 200 MCG TABLET [212415]
|
Facility
OP
|
$271.97
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
ERX212415
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.23 |
| Max. Negotiated Rate |
$231.17 |
| Rate for Payer: Adventist Health Commercial |
$54.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$145.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$186.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$231.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$149.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$203.98
|
| Rate for Payer: Blue Shield of California Commercial |
$168.89
|
| Rate for Payer: Blue Shield of California EPN |
$159.65
|
| Rate for Payer: Cash Price |
$122.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$176.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$231.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$231.17
|
| Rate for Payer: Dignity Health Senior |
$231.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$174.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$168.35
|
| Rate for Payer: Heritage Provider Network Senior |
$168.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$131.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.99
|
| Rate for Payer: Multiplan Commercial |
$203.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.17
|
| Rate for Payer: Vantage Medical Group Senior |
$231.17
|
|
