|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 6800140307
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.33
|
|
|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 6373941110
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 6800140407
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Senior |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 6808488201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0904712561
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 2780826501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 2780826501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 6586224708
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 6800140407
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Senior |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO |
$0.27
|
| Rate for Payer: United Healthcare HMO Rider |
$0.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 6808488201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 6586224708
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 7220509692
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 7220509692
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 6808488211
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0904712561
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 6808488211
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
LEVETIRACETAM ER 500 MG TABLET,EXTENDED RELEASE 24 HR [93834]
|
Facility
|
IP
|
$11.30
|
|
|
Service Code
|
NDC 5047459866
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$9.61 |
| Rate for Payer: Adventist Health Commercial |
$2.26
|
| Rate for Payer: Blue Shield of California Commercial |
$5.73
|
| Rate for Payer: Blue Shield of California Commercial |
$8.69
|
| Rate for Payer: Cash Price |
$5.09
|
| Rate for Payer: Cigna of CA HMO |
$7.91
|
| Rate for Payer: Cigna of CA PPO |
$7.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.52
|
| Rate for Payer: EPIC Health Plan Senior |
$4.52
|
| Rate for Payer: Galaxy Health WC |
$9.61
|
| Rate for Payer: Global Benefits Group Commercial |
$6.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.71
|
| Rate for Payer: Multiplan Commercial |
$9.04
|
| Rate for Payer: Networks By Design Commercial |
$7.34
|
| Rate for Payer: Prime Health Services Commercial |
$9.61
|
|
|
LEVETIRACETAM ER 500 MG TABLET,EXTENDED RELEASE 24 HR [93834]
|
Facility
|
OP
|
$11.30
|
|
|
Service Code
|
NDC 5047459866
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$9.61 |
| Rate for Payer: Adventist Health Commercial |
$2.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.25
|
| Rate for Payer: Cash Price |
$5.09
|
| Rate for Payer: Cigna of CA HMO |
$7.91
|
| Rate for Payer: Cigna of CA PPO |
$7.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.52
|
| Rate for Payer: EPIC Health Plan Senior |
$4.52
|
| Rate for Payer: Galaxy Health WC |
$9.61
|
| Rate for Payer: Global Benefits Group Commercial |
$6.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.91
|
| Rate for Payer: Multiplan Commercial |
$9.04
|
| Rate for Payer: Networks By Design Commercial |
$7.34
|
| Rate for Payer: Prime Health Services Commercial |
$9.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.65
|
| Rate for Payer: United Healthcare All Other HMO |
$5.65
|
| Rate for Payer: United Healthcare HMO Rider |
$5.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.61
|
| Rate for Payer: Vantage Medical Group Senior |
$9.61
|
|
|
LEVOBUNOLOL 0.5 % EYE DROPS [10394]
|
Facility
|
IP
|
$4.30
|
|
|
Service Code
|
NDC 2420850505
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$2.18
|
| Rate for Payer: Blue Shield of California Commercial |
$3.31
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO |
$3.01
|
| Rate for Payer: Cigna of CA PPO |
$3.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: EPIC Health Plan Senior |
$1.72
|
| Rate for Payer: Galaxy Health WC |
$3.65
|
| Rate for Payer: Global Benefits Group Commercial |
$2.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.44
|
| Rate for Payer: Networks By Design Commercial |
$2.79
|
| Rate for Payer: Prime Health Services Commercial |
$3.65
|
|
|
LEVOBUNOLOL 0.5 % EYE DROPS [10394]
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
NDC 2420850505
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO |
$3.01
|
| Rate for Payer: Cigna of CA PPO |
$3.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.65
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: EPIC Health Plan Senior |
$1.72
|
| Rate for Payer: Galaxy Health WC |
$3.65
|
| Rate for Payer: Global Benefits Group Commercial |
$2.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.01
|
| Rate for Payer: Multiplan Commercial |
$3.44
|
| Rate for Payer: Networks By Design Commercial |
$2.79
|
| Rate for Payer: Prime Health Services Commercial |
$3.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.15
|
| Rate for Payer: United Healthcare All Other HMO |
$2.15
|
| Rate for Payer: United Healthcare HMO Rider |
$2.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.65
|
| Rate for Payer: Vantage Medical Group Senior |
$3.65
|
|
|
LEVOCARNITINE 100 MG/ML ORAL SOLUTION [110335]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 7095414010
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.30
|
|
|
LEVOCARNITINE 100 MG/ML ORAL SOLUTION [110335]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 7095414010
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION [20954]
|
Facility
|
IP
|
$9.33
|
|
|
Service Code
|
HCPCS J1955
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$7.93 |
| Rate for Payer: Networks By Design Commercial |
$4.28
|
| Rate for Payer: Networks By Design Commercial |
$4.67
|
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Blue Shield of California Commercial |
$6.58
|
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California Commercial |
$7.17
|
| Rate for Payer: Blue Shield of California Commercial |
$4.34
|
| Rate for Payer: Cash Price |
$3.85
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna of CA HMO |
$6.53
|
| Rate for Payer: Cigna of CA HMO |
$5.99
|
| Rate for Payer: Cigna of CA PPO |
$5.99
|
| Rate for Payer: Cigna of CA PPO |
$6.53
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.99
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.73
|
| Rate for Payer: EPIC Health Plan Senior |
$3.42
|
| Rate for Payer: EPIC Health Plan Senior |
$3.73
|
| Rate for Payer: Galaxy Health WC |
$7.28
|
| Rate for Payer: Galaxy Health WC |
$7.93
|
| Rate for Payer: Global Benefits Group Commercial |
$5.60
|
| Rate for Payer: Global Benefits Group Commercial |
$5.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
| Rate for Payer: Multiplan Commercial |
$7.46
|
| Rate for Payer: Prime Health Services Commercial |
$7.93
|
| Rate for Payer: Prime Health Services Commercial |
$7.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.50
|
| Rate for Payer: United Healthcare All Other HMO |
$3.41
|
| Rate for Payer: United Healthcare All Other HMO |
$3.13
|
| Rate for Payer: United Healthcare HMO Rider |
$3.06
|
| Rate for Payer: United Healthcare HMO Rider |
$3.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.06
|
|
|
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION [20954]
|
Facility
|
OP
|
$9.33
|
|
|
Service Code
|
HCPCS J1955
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$153.31 |
| Rate for Payer: United Healthcare HMO Rider |
$3.06
|
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Aetna of CA HMO/PPO |
$153.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$153.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$90.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$90.91
|
| Rate for Payer: Blue Shield of California Commercial |
$42.80
|
| Rate for Payer: Blue Shield of California Commercial |
$42.80
|
| Rate for Payer: Cash Price |
$3.85
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$3.85
|
| Rate for Payer: Cigna of CA HMO |
$6.53
|
| Rate for Payer: Cigna of CA HMO |
$5.99
|
| Rate for Payer: Cigna of CA PPO |
$5.99
|
| Rate for Payer: Cigna of CA PPO |
$6.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.99
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.42
|
| Rate for Payer: EPIC Health Plan Senior |
$3.73
|
| Rate for Payer: EPIC Health Plan Senior |
$3.42
|
| Rate for Payer: Galaxy Health WC |
$7.93
|
| Rate for Payer: Galaxy Health WC |
$7.28
|
| Rate for Payer: Global Benefits Group Commercial |
$5.60
|
| Rate for Payer: Global Benefits Group Commercial |
$5.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.99
|
| Rate for Payer: Multiplan Commercial |
$7.46
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
| Rate for Payer: Networks By Design Commercial |
$4.67
|
| Rate for Payer: Networks By Design Commercial |
$4.28
|
| Rate for Payer: Prime Health Services Commercial |
$7.28
|
| Rate for Payer: Prime Health Services Commercial |
$7.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.50
|
| Rate for Payer: United Healthcare All Other HMO |
$3.13
|
| Rate for Payer: United Healthcare All Other HMO |
$3.41
|
| Rate for Payer: United Healthcare HMO Rider |
$3.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.93
|
| Rate for Payer: Vantage Medical Group Senior |
$7.28
|
| Rate for Payer: Vantage Medical Group Senior |
$7.93
|
|
|
LEVOCARNITINE 330 MG TABLET [20952]
|
Facility
|
IP
|
$1.05
|
|
|
Service Code
|
NDC 7095449210
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna of CA HMO |
$0.74
|
| Rate for Payer: Cigna of CA PPO |
$0.74
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: EPIC Health Plan Senior |
$0.42
|
| Rate for Payer: Galaxy Health WC |
$0.89
|
| Rate for Payer: Global Benefits Group Commercial |
$0.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
| Rate for Payer: Networks By Design Commercial |
$0.68
|
| Rate for Payer: Prime Health Services Commercial |
$0.89
|
|
