|
SIMETHICONE 80 MG CHEWABLE TABLET [7227]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 49348-188-10
|
| Hospital Charge Code |
1711183
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| 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 |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 12011
|
| Min. Negotiated Rate |
$113.83 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$131.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: IEHP Medi-Cal |
$113.83
|
| Rate for Payer: IEHP Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$475.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$275.15
|
| Rate for Payer: TriValley Medical Group Senior |
$250.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 12001
|
| Min. Negotiated Rate |
$109.18 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: IEHP Medi-Cal |
$109.18
|
| Rate for Payer: IEHP Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$475.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$275.15
|
| Rate for Payer: TriValley Medical Group Senior |
$250.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 12002
|
| Min. Negotiated Rate |
$142.02 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$142.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: IEHP Medi-Cal |
$162.55
|
| Rate for Payer: IEHP Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$475.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$275.15
|
| Rate for Payer: TriValley Medical Group Senior |
$250.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
SIMPLE SYRUP [7242]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 3172293747
|
| Hospital Charge Code |
ERX7242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| 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 |
$0.02
|
| 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 |
$0.03
|
|
|
SIMPLE SYRUP [7242]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 3172293747
|
| Hospital Charge Code |
ERX7242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| 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 |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SIMPLE SYRUP [7242]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 395266116
|
| Hospital Charge Code |
ERX7242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| 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 |
$0.02
|
| 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 |
$0.03
|
|
|
SIMPLE SYRUP [7242]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 395266116
|
| Hospital Charge Code |
ERX7242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| 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 |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SIMVASTATIN 20 MG TABLET [11365]
|
Facility
IP
|
$0.29
|
|
|
Service Code
|
NDC 68084-512-01
|
| Hospital Charge Code |
1711607
|
|
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
|
|
|
SIMVASTATIN 20 MG TABLET [11365]
|
Facility
OP
|
$0.29
|
|
|
Service Code
|
NDC 68084-512-01
|
| Hospital Charge Code |
1711607
|
|
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
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]
|
Facility
IP
|
$152.00
|
|
|
Service Code
|
CPT J2805
|
| Hospital Charge Code |
ERX11368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.51 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Adventist Health Commercial |
$30.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$104.42
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$82.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$102.90
|
| Rate for Payer: Heritage Provider Network Senior |
$102.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.00
|
| Rate for Payer: Multiplan Commercial |
$114.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$55.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$50.78
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]
|
Facility
OP
|
$152.00
|
|
|
Service Code
|
CPT J2805
|
| Hospital Charge Code |
ERX11368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.51 |
| Max. Negotiated Rate |
$326.97 |
| Rate for Payer: Adventist Health Commercial |
$30.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$326.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$104.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$129.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$83.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$114.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$114.97
|
| Rate for Payer: Blue Shield of California Commercial |
$103.19
|
| Rate for Payer: Blue Shield of California EPN |
$103.19
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$129.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$129.20
|
| Rate for Payer: Dignity Health Senior |
$129.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$70.38
|
| Rate for Payer: Heritage Provider Network Senior |
$70.38
|
| Rate for Payer: IEHP Medi-Cal |
$214.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$73.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.00
|
| Rate for Payer: Multiplan Commercial |
$114.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$55.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$50.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$129.20
|
| Rate for Payer: Vantage Medical Group Senior |
$129.20
|
|
|
Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps
|
Facility
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 31030
|
| Min. Negotiated Rate |
$139.39 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: IEHP Medi-Cal |
$139.39
|
| Rate for Payer: IEHP Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]
|
Facility
OP
|
$300.49
|
|
|
Service Code
|
CPT Q2043
|
| Hospital Charge Code |
1753491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.39 |
| Max. Negotiated Rate |
$131,249.15 |
| Rate for Payer: Adventist Health Commercial |
$60.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$131,249.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$206.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$66,783.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$58,769.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$58,769.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$66,250.26
|
| 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 |
$80,139.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$58,769.32
|
| Rate for Payer: Dignity Health Senior |
$58,769.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$192.31
|
| Rate for Payer: EPIC Health Plan Medicare |
$53,426.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$139.13
|
| Rate for Payer: Heritage Provider Network Senior |
$139.13
|
| Rate for Payer: Humana Medicare |
$53,426.66
|
| Rate for Payer: IEHP Medi-Cal |
$83,352.55
|
| Rate for Payer: IEHP Medicare Advantage |
$53,426.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$101,510.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63,043.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$67,317.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$67,317.59
|
| Rate for Payer: Multiplan Commercial |
$225.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$58,769.32
|
| Rate for Payer: TriValley Medical Group Senior |
$53,426.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$109.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$100.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$80,139.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$58,769.32
|
| Rate for Payer: Vantage Medical Group Senior |
$53,426.66
|
|
|
SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]
|
Facility
IP
|
$300.49
|
|
|
Service Code
|
CPT Q2043
|
| Hospital Charge Code |
1753491
|
|
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 |
$206.44
|
| 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 |
$203.43
|
| Rate for Payer: Heritage Provider Network Senior |
$203.43
|
| Rate for Payer: Kaiser Permanente of CA 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 |
$109.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$100.39
|
|
|
SIROLIMUS 0.5 MG TABLET [104764]
|
Facility
IP
|
$20.63
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1712518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$15.47 |
| Rate for Payer: Adventist Health Commercial |
$4.13
|
| Rate for Payer: Adventist Health Commercial |
$2.07
|
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.17
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.01
|
| Rate for Payer: Heritage Provider Network Senior |
$13.97
|
| Rate for Payer: Heritage Provider Network Senior |
$4.43
|
| Rate for Payer: Heritage Provider Network Senior |
$7.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.59
|
| Rate for Payer: Multiplan Commercial |
$7.76
|
| Rate for Payer: Multiplan Commercial |
$15.47
|
| Rate for Payer: Multiplan Commercial |
$4.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.46
|
|
|
SIROLIMUS 0.5 MG TABLET [104764]
|
Facility
OP
|
$10.35
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1712518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: Adventist Health Commercial |
$2.07
|
| Rate for Payer: Adventist Health Commercial |
$4.13
|
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.69
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.50
|
| Rate for Payer: Blue Shield of California Commercial |
$13.52
|
| Rate for Payer: Blue Shield of California Commercial |
$13.52
|
| Rate for Payer: Blue Shield of California Commercial |
$13.52
|
| Rate for Payer: Blue Shield of California EPN |
$13.52
|
| Rate for Payer: Blue Shield of California EPN |
$13.52
|
| Rate for Payer: Blue Shield of California EPN |
$13.52
|
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cash Price |
$2.95
|
| 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 |
$9.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.80
|
| Rate for Payer: Dignity Health Senior |
$5.57
|
| Rate for Payer: Dignity Health Senior |
$17.54
|
| Rate for Payer: Dignity Health Senior |
$8.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.79
|
| Rate for Payer: Heritage Provider Network Senior |
$9.55
|
| Rate for Payer: Heritage Provider Network Senior |
$3.03
|
| Rate for Payer: Heritage Provider Network Senior |
$4.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.16
|
| 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: Multiplan Commercial |
$7.76
|
| Rate for Payer: Multiplan Commercial |
$15.47
|
| Rate for Payer: Multiplan Commercial |
$4.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.80
|
| Rate for Payer: Vantage Medical Group Senior |
$8.80
|
| Rate for Payer: Vantage Medical Group Senior |
$17.54
|
| Rate for Payer: Vantage Medical Group Senior |
$5.57
|
|
|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
IP
|
$17.50
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1715200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$13.12 |
| Rate for Payer: Adventist Health Commercial |
$3.50
|
| Rate for Payer: Adventist Health Commercial |
$4.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.02
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.25
|
| Rate for Payer: Heritage Provider Network Senior |
$11.85
|
| Rate for Payer: Heritage Provider Network Senior |
$14.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$15.79
|
| Rate for Payer: Multiplan Commercial |
$13.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.03
|
|
|
SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]
|
Facility
OP
|
$17.50
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1715200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: Adventist Health Commercial |
$3.50
|
| Rate for Payer: Adventist Health Commercial |
$4.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.50
|
| Rate for Payer: Blue Shield of California Commercial |
$13.52
|
| Rate for Payer: Blue Shield of California Commercial |
$13.52
|
| Rate for Payer: Blue Shield of California EPN |
$13.52
|
| Rate for Payer: Blue Shield of California EPN |
$13.52
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cash Price |
$9.47
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.89
|
| Rate for Payer: Dignity Health Senior |
$14.88
|
| Rate for Payer: Dignity Health Senior |
$17.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.20
|
| 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 |
$8.10
|
| Rate for Payer: Heritage Provider Network Senior |
$8.10
|
| Rate for Payer: Heritage Provider Network Senior |
$9.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$15.79
|
| Rate for Payer: Multiplan Commercial |
$13.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.89
|
| Rate for Payer: Vantage Medical Group Senior |
$14.88
|
| Rate for Payer: Vantage Medical Group Senior |
$17.89
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
OP
|
$9.00
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1711808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Adventist Health Commercial |
$3.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.50
|
| Rate for Payer: Blue Shield of California Commercial |
$13.52
|
| Rate for Payer: Blue Shield of California Commercial |
$13.52
|
| Rate for Payer: Blue Shield of California EPN |
$13.52
|
| Rate for Payer: Blue Shield of California EPN |
$13.52
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.16
|
| Rate for Payer: Dignity Health Senior |
$7.65
|
| Rate for Payer: Dignity Health Senior |
$14.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.17
|
| Rate for Payer: Heritage Provider Network Senior |
$4.17
|
| Rate for Payer: Heritage Provider Network Senior |
$7.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$12.50
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.65
|
| Rate for Payer: Vantage Medical Group Senior |
$14.16
|
| Rate for Payer: Vantage Medical Group Senior |
$7.65
|
|
|
SIROLIMUS 1 MG TABLET [28958]
|
Facility
IP
|
$16.66
|
|
|
Service Code
|
CPT J7520
|
| Hospital Charge Code |
1711808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$12.50 |
| Rate for Payer: Adventist Health Commercial |
$3.33
|
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.18
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.28
|
| Rate for Payer: Heritage Provider Network Senior |
$6.09
|
| Rate for Payer: Heritage Provider Network Senior |
$11.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$12.50
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.01
|
|
|
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION [233123]
|
Facility
OP
|
$8,512.06
|
|
|
Service Code
|
NDC 80803-153-50
|
| Hospital Charge Code |
ERX233123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,540.68 |
| Max. Negotiated Rate |
$7,235.25 |
| Rate for Payer: Adventist Health Commercial |
$1,702.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4,549.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,847.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,235.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,681.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,384.04
|
| Rate for Payer: Blue Shield of California Commercial |
$5,285.99
|
| Rate for Payer: Blue Shield of California EPN |
$4,996.58
|
| Rate for Payer: Cash Price |
$3,830.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,915.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,235.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,235.25
|
| Rate for Payer: Dignity Health Senior |
$7,235.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,447.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,941.08
|
| Rate for Payer: Heritage Provider Network Senior |
$3,941.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,102.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,540.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,128.02
|
| Rate for Payer: Multiplan Commercial |
$6,384.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,103.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,843.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,235.25
|
| Rate for Payer: Vantage Medical Group Senior |
$7,235.25
|
|
|
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION [233123]
|
Facility
IP
|
$8,512.06
|
|
|
Service Code
|
NDC 80803-153-50
|
| Hospital Charge Code |
ERX233123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,540.68 |
| Max. Negotiated Rate |
$6,384.04 |
| Rate for Payer: Adventist Health Commercial |
$1,702.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,847.79
|
| Rate for Payer: Cash Price |
$3,830.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,915.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,596.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,762.66
|
| Rate for Payer: Heritage Provider Network Senior |
$5,762.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,540.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,128.02
|
| Rate for Payer: Multiplan Commercial |
$6,384.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,103.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,843.88
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0277-01
|
| Hospital Charge Code |
1711892
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Adventist Health Commercial |
$4.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.42
|
| Rate for Payer: Blue Shield of California Commercial |
$13.59
|
| Rate for Payer: Blue Shield of California EPN |
$12.85
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.61
|
| Rate for Payer: Dignity Health Senior |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.55
|
| Rate for Payer: Heritage Provider Network Senior |
$13.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.47
|
| Rate for Payer: Multiplan Commercial |
$16.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0277-31
|
| Hospital Charge Code |
1711892
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Adventist Health Commercial |
$4.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.42
|
| Rate for Payer: Blue Shield of California Commercial |
$13.59
|
| Rate for Payer: Blue Shield of California EPN |
$12.85
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.61
|
| Rate for Payer: Dignity Health Senior |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.55
|
| Rate for Payer: Heritage Provider Network Senior |
$13.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.47
|
| Rate for Payer: Multiplan Commercial |
$16.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
