|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9015]
|
Facility
OP
|
$0.13
|
|
|
Service Code
|
NDC 0121-1762-30
|
| Hospital Charge Code |
NDG9015
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: BCBS Transplant Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Media |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| 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 |
$0.11
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9015]
|
Facility
IP
|
$0.13
|
|
|
Service Code
|
NDC 0121-1762-30
|
| Hospital Charge Code |
NDG9015
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| 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 |
$0.11
|
|
|
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION [37605]
|
Facility
OP
|
$0.15
|
|
|
Service Code
|
NDC 0121-1760-30
|
| Hospital Charge Code |
1719150
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: BCBS Transplant Transplant |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Media |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION [37605]
|
Facility
IP
|
$0.15
|
|
|
Service Code
|
NDC 0121-1760-30
|
| Hospital Charge Code |
1719150
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
|
|
ALVIMOPAN 12 MG CAPSULE [91870]
|
Facility
IP
|
$218.21
|
|
|
Service Code
|
NDC 67919-020-10
|
| Hospital Charge Code |
ERX91870
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$52.37 |
| Max. Negotiated Rate |
$185.48 |
| Rate for Payer: Cash Price |
$98.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$87.28
|
| Rate for Payer: Galaxy Health WC |
$185.48
|
| Rate for Payer: Global Benefits Group Commercial |
$130.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$145.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$83.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.37
|
| Rate for Payer: Multiplan Commercial |
$174.57
|
| Rate for Payer: Networks By Design Commercial |
$141.84
|
| Rate for Payer: Prime Health Services Commercial |
$185.48
|
|
|
ALVIMOPAN 12 MG CAPSULE [91870]
|
Facility
OP
|
$218.21
|
|
|
Service Code
|
NDC 67919-020-10
|
| Hospital Charge Code |
ERX91870
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$52.37 |
| Max. Negotiated Rate |
$185.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$143.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$185.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$120.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$120.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$130.01
|
| Rate for Payer: BCBS Transplant Transplant |
$130.93
|
| Rate for Payer: Blue Shield of California Commercial |
$160.82
|
| Rate for Payer: Blue Shield of California EPN |
$127.43
|
| Rate for Payer: Cash Price |
$98.19
|
| Rate for Payer: Cigna of CA HMO |
$139.65
|
| Rate for Payer: Cigna of CA PPO |
$161.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$185.48
|
| Rate for Payer: Dignity Health Media |
$185.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$185.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$87.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$87.28
|
| Rate for Payer: Galaxy Health WC |
$185.48
|
| Rate for Payer: Global Benefits Group Commercial |
$130.93
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$163.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$145.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$83.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.37
|
| Rate for Payer: Multiplan Commercial |
$174.57
|
| Rate for Payer: Networks By Design Commercial |
$141.84
|
| Rate for Payer: Prime Health Services Commercial |
$185.48
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$130.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$130.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$130.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$109.10
|
| Rate for Payer: United Healthcare All Other HMO |
$109.10
|
| Rate for Payer: United Healthcare HMO Rider |
$109.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$109.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$185.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$185.48
|
| Rate for Payer: Vantage Medical Group Senior |
$185.48
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
OP
|
$0.12
|
|
|
Service Code
|
NDC 16571-834-01
|
| Hospital Charge Code |
1710713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: BCBS Transplant Transplant |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| 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 Media |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.07
|
| 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
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
OP
|
$0.48
|
|
|
Service Code
|
NDC 42543-493-01
|
| Hospital Charge Code |
1710713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: BCBS Transplant Transplant |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Media |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| 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 |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
IP
|
$0.48
|
|
|
Service Code
|
NDC 42543-493-01
|
| Hospital Charge Code |
1710713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
IP
|
$0.97
|
|
|
Service Code
|
NDC 68382-512-01
|
| Hospital Charge Code |
1710713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Blue Shield of California Commercial |
$0.69
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO |
$0.68
|
| Rate for Payer: Cigna of CA PPO |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
IP
|
$0.12
|
|
|
Service Code
|
NDC 16571-834-01
|
| Hospital Charge Code |
1710713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| 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: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| 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
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
OP
|
$0.97
|
|
|
Service Code
|
NDC 68382-512-01
|
| Hospital Charge Code |
1710713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.58
|
| Rate for Payer: BCBS Transplant Transplant |
$0.58
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.57
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO |
$0.68
|
| Rate for Payer: Cigna of CA PPO |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Media |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO |
$0.49
|
| Rate for Payer: United Healthcare HMO Rider |
$0.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
IP
|
$0.97
|
|
|
Service Code
|
NDC 0832-1015-00
|
| Hospital Charge Code |
1710713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Blue Shield of California Commercial |
$0.69
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO |
$0.68
|
| Rate for Payer: Cigna of CA PPO |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
OP
|
$0.97
|
|
|
Service Code
|
NDC 0832-1015-00
|
| Hospital Charge Code |
1710713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.58
|
| Rate for Payer: BCBS Transplant Transplant |
$0.58
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.57
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO |
$0.68
|
| Rate for Payer: Cigna of CA PPO |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Media |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO |
$0.49
|
| Rate for Payer: United Healthcare HMO Rider |
$0.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
NDC 0121-0646-16
|
| Hospital Charge Code |
1715916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 0121-0646-16
|
| Hospital Charge Code |
1715916
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: BCBS Transplant Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Media |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
OP
|
$450.38
|
|
|
Service Code
|
NDC 61958-0802-5
|
| Hospital Charge Code |
1712539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$108.09 |
| Max. Negotiated Rate |
$382.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$295.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$382.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$247.71
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$247.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$268.34
|
| Rate for Payer: BCBS Transplant Transplant |
$270.23
|
| Rate for Payer: Blue Shield of California Commercial |
$331.93
|
| Rate for Payer: Blue Shield of California EPN |
$263.02
|
| Rate for Payer: Cash Price |
$202.67
|
| Rate for Payer: Cigna of CA HMO |
$315.27
|
| Rate for Payer: Cigna of CA PPO |
$315.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$382.82
|
| Rate for Payer: Dignity Health Media |
$382.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$382.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$180.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$180.15
|
| Rate for Payer: Galaxy Health WC |
$382.82
|
| Rate for Payer: Global Benefits Group Commercial |
$270.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$337.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$300.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$171.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.09
|
| Rate for Payer: Multiplan Commercial |
$360.30
|
| Rate for Payer: Networks By Design Commercial |
$292.75
|
| Rate for Payer: Prime Health Services Commercial |
$382.82
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$270.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$270.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$270.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$225.19
|
| Rate for Payer: United Healthcare All Other HMO |
$225.19
|
| Rate for Payer: United Healthcare HMO Rider |
$225.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$225.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$382.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$382.82
|
| Rate for Payer: Vantage Medical Group Senior |
$382.82
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
IP
|
$450.38
|
|
|
Service Code
|
NDC 61958-0802-5
|
| Hospital Charge Code |
1712539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$108.09 |
| Max. Negotiated Rate |
$382.82 |
| Rate for Payer: Blue Shield of California Commercial |
$320.67
|
| Rate for Payer: Blue Shield of California EPN |
$230.59
|
| Rate for Payer: Cash Price |
$202.67
|
| Rate for Payer: Cigna of CA HMO |
$315.27
|
| Rate for Payer: Cigna of CA PPO |
$315.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$180.15
|
| Rate for Payer: Galaxy Health WC |
$382.82
|
| Rate for Payer: Global Benefits Group Commercial |
$270.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$300.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$171.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.09
|
| Rate for Payer: Multiplan Commercial |
$360.30
|
| Rate for Payer: Networks By Design Commercial |
$292.75
|
| Rate for Payer: Prime Health Services Commercial |
$382.82
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
IP
|
$450.38
|
|
|
Service Code
|
NDC 61958-0802-1
|
| Hospital Charge Code |
1712539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$108.09 |
| Max. Negotiated Rate |
$382.82 |
| Rate for Payer: Blue Shield of California Commercial |
$320.67
|
| Rate for Payer: Blue Shield of California EPN |
$230.59
|
| Rate for Payer: Cash Price |
$202.67
|
| Rate for Payer: Cigna of CA HMO |
$315.27
|
| Rate for Payer: Cigna of CA PPO |
$315.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$180.15
|
| Rate for Payer: Galaxy Health WC |
$382.82
|
| Rate for Payer: Global Benefits Group Commercial |
$270.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$300.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$171.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.09
|
| Rate for Payer: Multiplan Commercial |
$360.30
|
| Rate for Payer: Networks By Design Commercial |
$292.75
|
| Rate for Payer: Prime Health Services Commercial |
$382.82
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
OP
|
$46.08
|
|
|
Service Code
|
NDC 47335-237-83
|
| Hospital Charge Code |
1712539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.06 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$30.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.45
|
| Rate for Payer: BCBS Transplant Transplant |
$27.65
|
| Rate for Payer: Blue Shield of California Commercial |
$33.96
|
| Rate for Payer: Blue Shield of California EPN |
$26.91
|
| Rate for Payer: Cash Price |
$20.74
|
| Rate for Payer: Cigna of CA HMO |
$32.26
|
| Rate for Payer: Cigna of CA PPO |
$32.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.17
|
| Rate for Payer: Dignity Health Media |
$39.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.43
|
| Rate for Payer: Galaxy Health WC |
$39.17
|
| Rate for Payer: Global Benefits Group Commercial |
$27.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$34.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.06
|
| Rate for Payer: Multiplan Commercial |
$36.86
|
| Rate for Payer: Networks By Design Commercial |
$29.95
|
| Rate for Payer: Prime Health Services Commercial |
$39.17
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$27.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.04
|
| Rate for Payer: United Healthcare All Other HMO |
$23.04
|
| Rate for Payer: United Healthcare HMO Rider |
$23.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.17
|
| Rate for Payer: Vantage Medical Group Senior |
$39.17
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
OP
|
$450.38
|
|
|
Service Code
|
NDC 61958-0802-1
|
| Hospital Charge Code |
1712539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$108.09 |
| Max. Negotiated Rate |
$382.82 |
| Rate for Payer: BCBS Transplant Transplant |
$270.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$295.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$382.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$247.71
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$247.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$268.34
|
| Rate for Payer: Blue Shield of California Commercial |
$331.93
|
| Rate for Payer: Blue Shield of California EPN |
$263.02
|
| Rate for Payer: Cash Price |
$202.67
|
| Rate for Payer: Cigna of CA HMO |
$315.27
|
| Rate for Payer: Cigna of CA PPO |
$315.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$382.82
|
| Rate for Payer: Dignity Health Media |
$382.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$382.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$180.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$180.15
|
| Rate for Payer: Galaxy Health WC |
$382.82
|
| Rate for Payer: Global Benefits Group Commercial |
$270.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$337.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$300.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$171.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.09
|
| Rate for Payer: Multiplan Commercial |
$360.30
|
| Rate for Payer: Networks By Design Commercial |
$292.75
|
| Rate for Payer: Prime Health Services Commercial |
$382.82
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$270.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$270.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$270.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$225.19
|
| Rate for Payer: United Healthcare All Other HMO |
$225.19
|
| Rate for Payer: United Healthcare HMO Rider |
$225.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$225.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$382.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$382.82
|
| Rate for Payer: Vantage Medical Group Senior |
$382.82
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
IP
|
$46.08
|
|
|
Service Code
|
NDC 47335-237-83
|
| Hospital Charge Code |
1712539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.06 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Blue Shield of California Commercial |
$32.81
|
| Rate for Payer: Blue Shield of California EPN |
$23.59
|
| Rate for Payer: Cash Price |
$20.74
|
| Rate for Payer: Cigna of CA HMO |
$32.26
|
| Rate for Payer: Cigna of CA PPO |
$32.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.43
|
| Rate for Payer: Galaxy Health WC |
$39.17
|
| Rate for Payer: Global Benefits Group Commercial |
$27.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.06
|
| Rate for Payer: Multiplan Commercial |
$36.86
|
| Rate for Payer: Networks By Design Commercial |
$29.95
|
| Rate for Payer: Prime Health Services Commercial |
$39.17
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
OP
|
$46.08
|
|
|
Service Code
|
NDC 47335-236-83
|
| Hospital Charge Code |
ERX82307
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.06 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$30.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.45
|
| Rate for Payer: BCBS Transplant Transplant |
$27.65
|
| Rate for Payer: Blue Shield of California Commercial |
$33.96
|
| Rate for Payer: Blue Shield of California EPN |
$26.91
|
| Rate for Payer: Cash Price |
$20.74
|
| Rate for Payer: Cigna of CA HMO |
$32.26
|
| Rate for Payer: Cigna of CA PPO |
$32.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.17
|
| Rate for Payer: Dignity Health Media |
$39.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.43
|
| Rate for Payer: Galaxy Health WC |
$39.17
|
| Rate for Payer: Global Benefits Group Commercial |
$27.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$34.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.06
|
| Rate for Payer: Multiplan Commercial |
$36.86
|
| Rate for Payer: Networks By Design Commercial |
$29.95
|
| Rate for Payer: Prime Health Services Commercial |
$39.17
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$27.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.04
|
| Rate for Payer: United Healthcare All Other HMO |
$23.04
|
| Rate for Payer: United Healthcare HMO Rider |
$23.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.17
|
| Rate for Payer: Vantage Medical Group Senior |
$39.17
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
IP
|
$46.08
|
|
|
Service Code
|
NDC 47335-236-83
|
| Hospital Charge Code |
ERX82307
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.06 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Blue Shield of California Commercial |
$32.81
|
| Rate for Payer: Blue Shield of California EPN |
$23.59
|
| Rate for Payer: Cash Price |
$20.74
|
| Rate for Payer: Cigna of CA HMO |
$32.26
|
| Rate for Payer: Cigna of CA PPO |
$32.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.43
|
| Rate for Payer: Galaxy Health WC |
$39.17
|
| Rate for Payer: Global Benefits Group Commercial |
$27.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.06
|
| Rate for Payer: Multiplan Commercial |
$36.86
|
| Rate for Payer: Networks By Design Commercial |
$29.95
|
| Rate for Payer: Prime Health Services Commercial |
$39.17
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
IP
|
$450.38
|
|
|
Service Code
|
NDC 61958-0801-5
|
| Hospital Charge Code |
ERX82307
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$108.09 |
| Max. Negotiated Rate |
$382.82 |
| Rate for Payer: Blue Shield of California Commercial |
$320.67
|
| Rate for Payer: Blue Shield of California EPN |
$230.59
|
| Rate for Payer: Cash Price |
$202.67
|
| Rate for Payer: Cigna of CA HMO |
$315.27
|
| Rate for Payer: Cigna of CA PPO |
$315.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$180.15
|
| Rate for Payer: Galaxy Health WC |
$382.82
|
| Rate for Payer: Global Benefits Group Commercial |
$270.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$300.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$171.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.09
|
| Rate for Payer: Multiplan Commercial |
$360.30
|
| Rate for Payer: Networks By Design Commercial |
$292.75
|
| Rate for Payer: Prime Health Services Commercial |
$382.82
|
|
