|
AMIODARONE 200 MG TABLET [9066]
|
Facility
IP
|
$0.44
|
|
|
Service Code
|
NDC 60687-437-11
|
| Hospital Charge Code |
1712089
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
OP
|
$0.44
|
|
|
Service Code
|
NDC 68084-371-01
|
| Hospital Charge Code |
1712089
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: BCBS Transplant Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Media |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
OP
|
$0.24
|
|
|
Service Code
|
NDC 72888-039-60
|
| Hospital Charge Code |
1712089
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: BCBS Transplant Transplant |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Media |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]
|
Facility
OP
|
$0.91
|
|
|
Service Code
|
CPT J0282
|
| Hospital Charge Code |
1721120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$58.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$58.58
|
| Rate for Payer: BCBS Transplant Transplant |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Media |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]
|
Facility
OP
|
$0.80
|
|
|
Service Code
|
CPT J0282
|
| Hospital Charge Code |
1759831
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$58.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$58.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$58.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$58.58
|
| Rate for Payer: BCBS Transplant Transplant |
$0.48
|
| Rate for Payer: BCBS Transplant Transplant |
$0.83
|
| Rate for Payer: BCBS Transplant Transplant |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA HMO |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.97
|
| Rate for Payer: Cigna of CA PPO |
$0.49
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Media |
$0.68
|
| Rate for Payer: Dignity Health Media |
$1.18
|
| Rate for Payer: Dignity Health Media |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$1.18
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.83
|
| Rate for Payer: Global Benefits Group Commercial |
$0.42
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.53
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.11
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.35
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Prime Health Services Commercial |
$1.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.70
|
| Rate for Payer: United Healthcare HMO Rider |
$0.70
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$1.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]
|
Facility
IP
|
$0.70
|
|
|
Service Code
|
CPT J0282
|
| Hospital Charge Code |
1759831
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.97
|
| Rate for Payer: Cigna of CA HMO |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.97
|
| Rate for Payer: Cigna of CA PPO |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.18
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.83
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$1.11
|
| Rate for Payer: Networks By Design Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.35
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Prime Health Services Commercial |
$1.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
|
|
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]
|
Facility
OP
|
$0.64
|
|
|
Service Code
|
CPT J0282
|
| Hospital Charge Code |
1720997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$58.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$58.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$58.58
|
| Rate for Payer: BCBS Transplant Transplant |
$0.56
|
| Rate for Payer: BCBS Transplant Transplant |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA HMO |
$0.66
|
| Rate for Payer: Cigna of CA PPO |
$0.66
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: Dignity Health Media |
$0.54
|
| Rate for Payer: Dignity Health Media |
$0.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
| Rate for Payer: Prime Health Services Commercial |
$0.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]
|
Facility
IP
|
$0.64
|
|
|
Service Code
|
CPT J0282
|
| Hospital Charge Code |
1720997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.66
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.80
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
|
|
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]
|
Facility
IP
|
$0.91
|
|
|
Service Code
|
CPT J0282
|
| Hospital Charge Code |
1721120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
|
AMIODARONE ORAL SUSPENSION COMPOUND 5 MG/ML [4080238]
|
Facility
OP
|
$0.32
|
|
|
Service Code
|
NDC 9994-0802-38
|
| Hospital Charge Code |
1715952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: BCBS Transplant Transplant |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Media |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO |
$0.16
|
| Rate for Payer: United Healthcare HMO Rider |
$0.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
AMIODARONE ORAL SUSPENSION COMPOUND 5 MG/ML [4080238]
|
Facility
IP
|
$0.32
|
|
|
Service Code
|
NDC 9994-0802-38
|
| Hospital Charge Code |
1715952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
|
|
AMITRIPTYLINE 100 MG TABLET [433]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 16729-175-01
|
| Hospital Charge Code |
1711133
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: BCBS Transplant Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| 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 |
$0.31
|
| Rate for Payer: Dignity Health Media |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| 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 |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
AMITRIPTYLINE 100 MG TABLET [433]
|
Facility
OP
|
$1.37
|
|
|
Service Code
|
NDC 51079-563-01
|
| Hospital Charge Code |
1711133
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.82
|
| Rate for Payer: BCBS Transplant Transplant |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$1.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna of CA HMO |
$0.96
|
| Rate for Payer: Cigna of CA PPO |
$0.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.16
|
| Rate for Payer: Dignity Health Media |
$1.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.55
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
| Rate for Payer: Networks By Design Commercial |
$0.89
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.69
|
| Rate for Payer: United Healthcare All Other HMO |
$0.69
|
| Rate for Payer: United Healthcare HMO Rider |
$0.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Vantage Medical Group Senior |
$1.16
|
|
|
AMITRIPTYLINE 100 MG TABLET [433]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 16729-175-01
|
| Hospital Charge Code |
1711133
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| 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: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
AMITRIPTYLINE 100 MG TABLET [433]
|
Facility
IP
|
$1.37
|
|
|
Service Code
|
NDC 51079-563-01
|
| Hospital Charge Code |
1711133
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Multiplan Commercial |
$1.10
|
| Rate for Payer: Networks By Design Commercial |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna of CA HMO |
$0.96
|
| Rate for Payer: Cigna of CA PPO |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
|
|
AMITRIPTYLINE 10 MG TABLET [432]
|
Facility
OP
|
$0.12
|
|
|
Service Code
|
NDC 29300-419-01
|
| Hospital Charge Code |
1710364
|
|
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
|
|
|
AMITRIPTYLINE 10 MG TABLET [432]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 57664-687-88
|
| Hospital Charge Code |
1710364
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| 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 |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
AMITRIPTYLINE 10 MG TABLET [432]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
NDC 57664-687-88
|
| Hospital Charge Code |
1710364
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: BCBS Transplant Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| 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 |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
AMITRIPTYLINE 10 MG TABLET [432]
|
Facility
IP
|
$0.12
|
|
|
Service Code
|
NDC 29300-419-01
|
| Hospital Charge Code |
1710364
|
|
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
|
|
|
AMITRIPTYLINE 25 MG TABLET [435]
|
Facility
OP
|
$0.52
|
|
|
Service Code
|
NDC 60687-433-01
|
| Hospital Charge Code |
1710373
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: BCBS Transplant Transplant |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.44
|
| Rate for Payer: Dignity Health Media |
$0.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.44
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.44
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO |
$0.26
|
| Rate for Payer: United Healthcare HMO Rider |
$0.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Vantage Medical Group Senior |
$0.44
|
|
|
AMITRIPTYLINE 25 MG TABLET [435]
|
Facility
IP
|
$0.52
|
|
|
Service Code
|
NDC 60687-433-11
|
| Hospital Charge Code |
1710373
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.44
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.44
|
|
|
AMITRIPTYLINE 25 MG TABLET [435]
|
Facility
OP
|
$0.52
|
|
|
Service Code
|
NDC 60687-433-11
|
| Hospital Charge Code |
1710373
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: BCBS Transplant Transplant |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.44
|
| Rate for Payer: Dignity Health Media |
$0.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.44
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.44
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO |
$0.26
|
| Rate for Payer: United Healthcare HMO Rider |
$0.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Vantage Medical Group Senior |
$0.44
|
|
|
AMITRIPTYLINE 25 MG TABLET [435]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 16729-172-01
|
| Hospital Charge Code |
1710373
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: BCBS Transplant Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
AMITRIPTYLINE 25 MG TABLET [435]
|
Facility
IP
|
$0.34
|
|
|
Service Code
|
NDC 0603-2213-21
|
| Hospital Charge Code |
1710373
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| 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: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| 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
|
|
|
AMITRIPTYLINE 25 MG TABLET [435]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 16729-172-01
|
| Hospital Charge Code |
1710373
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
