|
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]
|
Facility
OP
|
$0.89
|
|
|
Service Code
|
CPT S0090
|
| Hospital Charge Code |
1711956
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$55.66 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$55.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$55.66
|
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.76
|
| Rate for Payer: Dignity Health Senior |
$0.76
|
| Rate for Payer: Dignity Health Senior |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.76
|
| Rate for Payer: Vantage Medical Group Senior |
$0.76
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
SILTUXIMAB 100 MG INTRAVENOUS SOLUTION [205871]
|
Facility
OP
|
$1,703.24
|
|
|
Service Code
|
CPT J2860
|
| Hospital Charge Code |
ERX205871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$135.30 |
| Max. Negotiated Rate |
$1,277.43 |
| Rate for Payer: Adventist Health Commercial |
$340.65
|
| Rate for Payer: Aetna of CA Gatekeeper |
$365.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,170.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$186.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$163.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$163.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$183.40
|
| Rate for Payer: Blue Shield of California Commercial |
$135.30
|
| Rate for Payer: Blue Shield of California EPN |
$135.30
|
| Rate for Payer: Cash Price |
$766.46
|
| Rate for Payer: Cash Price |
$766.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$783.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$223.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$163.84
|
| Rate for Payer: Dignity Health Senior |
$163.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,090.07
|
| Rate for Payer: EPIC Health Plan Medicare |
$148.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$788.60
|
| Rate for Payer: Heritage Provider Network Senior |
$788.60
|
| Rate for Payer: Humana Medicare |
$148.94
|
| Rate for Payer: IEHP Medi-Cal |
$239.30
|
| Rate for Payer: IEHP Medicare Advantage |
$148.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$282.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$308.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$175.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$425.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$187.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$187.67
|
| Rate for Payer: Multiplan Commercial |
$1,277.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$163.84
|
| Rate for Payer: TriValley Medical Group Senior |
$148.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$621.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$569.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$223.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$163.84
|
| Rate for Payer: Vantage Medical Group Senior |
$148.94
|
|
|
SILTUXIMAB 100 MG INTRAVENOUS SOLUTION [205871]
|
Facility
IP
|
$1,703.24
|
|
|
Service Code
|
CPT J2860
|
| Hospital Charge Code |
ERX205871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$308.29 |
| Max. Negotiated Rate |
$1,277.43 |
| Rate for Payer: Adventist Health Commercial |
$340.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,170.13
|
| Rate for Payer: Cash Price |
$766.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$783.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$919.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,153.09
|
| Rate for Payer: Heritage Provider Network Senior |
$1,153.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$308.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$425.81
|
| Rate for Payer: Multiplan Commercial |
$1,277.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$621.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$569.05
|
|
|
SILTUXIMAB 400 MG INTRAVENOUS SOLUTION [205872]
|
Facility
IP
|
$6,812.98
|
|
|
Service Code
|
CPT J2860
|
| Hospital Charge Code |
ERX205872
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,233.15 |
| Max. Negotiated Rate |
$5,109.74 |
| Rate for Payer: Adventist Health Commercial |
$1,362.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,680.52
|
| Rate for Payer: Cash Price |
$3,065.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,133.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,679.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,612.39
|
| Rate for Payer: Heritage Provider Network Senior |
$4,612.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,233.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,703.24
|
| Rate for Payer: Multiplan Commercial |
$5,109.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,484.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,276.22
|
|
|
SILTUXIMAB 400 MG INTRAVENOUS SOLUTION [205872]
|
Facility
OP
|
$6,812.98
|
|
|
Service Code
|
CPT J2860
|
| Hospital Charge Code |
ERX205872
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$135.30 |
| Max. Negotiated Rate |
$5,109.74 |
| Rate for Payer: Adventist Health Commercial |
$1,362.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$365.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,680.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$186.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$163.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$163.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$183.40
|
| Rate for Payer: Blue Shield of California Commercial |
$135.30
|
| Rate for Payer: Blue Shield of California EPN |
$135.30
|
| Rate for Payer: Cash Price |
$3,065.84
|
| Rate for Payer: Cash Price |
$3,065.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,133.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$223.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$163.84
|
| Rate for Payer: Dignity Health Senior |
$163.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,360.31
|
| Rate for Payer: EPIC Health Plan Medicare |
$148.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,154.41
|
| Rate for Payer: Heritage Provider Network Senior |
$3,154.41
|
| Rate for Payer: Humana Medicare |
$148.94
|
| Rate for Payer: IEHP Medi-Cal |
$239.30
|
| Rate for Payer: IEHP Medicare Advantage |
$148.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$282.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,233.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$175.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,703.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$187.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$187.67
|
| Rate for Payer: Multiplan Commercial |
$5,109.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$163.84
|
| Rate for Payer: TriValley Medical Group Senior |
$148.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,484.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,276.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$223.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$163.84
|
| Rate for Payer: Vantage Medical Group Senior |
$148.94
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]
|
Facility
OP
|
$0.69
|
|
|
Service Code
|
NDC 8327030909
|
| Hospital Charge Code |
1743694
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: Dignity Health Senior |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]
|
Facility
IP
|
$0.69
|
|
|
Service Code
|
NDC 8019629660
|
| Hospital Charge Code |
1743694
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Senior |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]
|
Facility
IP
|
$0.69
|
|
|
Service Code
|
NDC 8327030909
|
| Hospital Charge Code |
1743694
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Senior |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE [116931]
|
Facility
OP
|
$0.69
|
|
|
Service Code
|
NDC 8019629660
|
| Hospital Charge Code |
1743694
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: Dignity Health Senior |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]
|
Facility
OP
|
$0.91
|
|
|
Service Code
|
NDC 12870-0001-1
|
| Hospital Charge Code |
1772054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Senior |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]
|
Facility
IP
|
$0.84
|
|
|
Service Code
|
NDC 12870-0001-2
|
| Hospital Charge Code |
1772054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.58
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Senior |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]
|
Facility
OP
|
$0.84
|
|
|
Service Code
|
NDC 12870-0001-2
|
| Hospital Charge Code |
1772054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.63
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Senior |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Senior |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]
|
Facility
IP
|
$0.91
|
|
|
Service Code
|
NDC 12870-0001-1
|
| Hospital Charge Code |
1772054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
IP
|
$0.29
|
|
|
Service Code
|
NDC 67877-124-50
|
| Hospital Charge Code |
1743179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| 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 Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
OP
|
$0.29
|
|
|
Service Code
|
NDC 67877-124-05
|
| Hospital Charge Code |
1743179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Senior |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
OP
|
$0.29
|
|
|
Service Code
|
NDC 67877-124-50
|
| Hospital Charge Code |
1743179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Senior |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
OP
|
$0.30
|
|
|
Service Code
|
NDC 61570-131-55
|
| Hospital Charge Code |
1743179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
IP
|
$0.30
|
|
|
Service Code
|
NDC 61570-131-55
|
| Hospital Charge Code |
1743179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| 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 Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 43598-210-25
|
| Hospital Charge Code |
1743588
|
|
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
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 67877-124-25
|
| Hospital Charge Code |
1743588
|
|
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
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
IP
|
$0.30
|
|
|
Service Code
|
NDC 43598-210-50
|
| Hospital Charge Code |
1743179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| 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 Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
OP
|
$0.30
|
|
|
Service Code
|
NDC 43598-210-50
|
| Hospital Charge Code |
1743179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
IP
|
$0.29
|
|
|
Service Code
|
NDC 67877-124-05
|
| Hospital Charge Code |
1743179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| 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 Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 43598-210-25
|
| Hospital Charge Code |
1743588
|
|
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
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 67877-124-25
|
| Hospital Charge Code |
1743588
|
|
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
|
|
