|
ISOTRETINOIN 10 MG CAPSULE [10359]
|
Facility
IP
|
$6.02
|
|
|
Service Code
|
NDC 0378-6611-93
|
| Hospital Charge Code |
1710001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Blue Shield of California Commercial |
$4.29
|
| Rate for Payer: Blue Shield of California EPN |
$3.08
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna of CA HMO |
$4.21
|
| Rate for Payer: Cigna of CA PPO |
$4.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.12
|
| Rate for Payer: Global Benefits Group Commercial |
$3.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: Networks By Design Commercial |
$3.91
|
| Rate for Payer: Prime Health Services Commercial |
$5.12
|
|
|
ISOTRETINOIN 10 MG CAPSULE [10359]
|
Facility
OP
|
$8.58
|
|
|
Service Code
|
NDC 61748-301-13
|
| Hospital Charge Code |
1710001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$7.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.63
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.11
|
| Rate for Payer: BCBS Transplant Transplant |
$5.15
|
| Rate for Payer: Blue Shield of California Commercial |
$6.32
|
| Rate for Payer: Blue Shield of California EPN |
$5.01
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Cigna of CA HMO |
$6.01
|
| Rate for Payer: Cigna of CA PPO |
$6.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.29
|
| Rate for Payer: Dignity Health Media |
$7.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.43
|
| Rate for Payer: Galaxy Health WC |
$7.29
|
| Rate for Payer: Global Benefits Group Commercial |
$5.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.06
|
| Rate for Payer: Multiplan Commercial |
$6.86
|
| Rate for Payer: Networks By Design Commercial |
$5.58
|
| Rate for Payer: Prime Health Services Commercial |
$7.29
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Other HMO |
$4.29
|
| Rate for Payer: United Healthcare HMO Rider |
$4.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.29
|
| Rate for Payer: Vantage Medical Group Senior |
$7.29
|
|
|
ISOTRETINOIN 10 MG CAPSULE [10359]
|
Facility
IP
|
$8.58
|
|
|
Service Code
|
NDC 61748-301-13
|
| Hospital Charge Code |
1710001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$7.29 |
| Rate for Payer: Blue Shield of California Commercial |
$6.11
|
| Rate for Payer: Blue Shield of California EPN |
$4.39
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Cigna of CA HMO |
$6.01
|
| Rate for Payer: Cigna of CA PPO |
$6.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.43
|
| Rate for Payer: Galaxy Health WC |
$7.29
|
| Rate for Payer: Global Benefits Group Commercial |
$5.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.06
|
| Rate for Payer: Multiplan Commercial |
$6.86
|
| Rate for Payer: Networks By Design Commercial |
$5.58
|
| Rate for Payer: Prime Health Services Commercial |
$7.29
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
OP
|
$7.14
|
|
|
Service Code
|
NDC 0378-6612-93
|
| Hospital Charge Code |
1710827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.25
|
| Rate for Payer: BCBS Transplant Transplant |
$4.28
|
| Rate for Payer: Blue Shield of California Commercial |
$5.26
|
| Rate for Payer: Blue Shield of California EPN |
$4.17
|
| Rate for Payer: Cash Price |
$3.21
|
| Rate for Payer: Cigna of CA HMO |
$5.00
|
| Rate for Payer: Cigna of CA PPO |
$5.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.07
|
| Rate for Payer: Dignity Health Media |
$6.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.86
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.86
|
| Rate for Payer: Galaxy Health WC |
$6.07
|
| Rate for Payer: Global Benefits Group Commercial |
$4.28
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.71
|
| Rate for Payer: Multiplan Commercial |
$5.71
|
| Rate for Payer: Networks By Design Commercial |
$4.64
|
| Rate for Payer: Prime Health Services Commercial |
$6.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.57
|
| Rate for Payer: United Healthcare All Other HMO |
$3.57
|
| Rate for Payer: United Healthcare HMO Rider |
$3.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.07
|
| Rate for Payer: Vantage Medical Group Senior |
$6.07
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
OP
|
$9.94
|
|
|
Service Code
|
NDC 61748-302-11
|
| Hospital Charge Code |
1710827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$8.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.92
|
| Rate for Payer: BCBS Transplant Transplant |
$5.96
|
| Rate for Payer: Blue Shield of California Commercial |
$7.33
|
| Rate for Payer: Blue Shield of California EPN |
$5.80
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Cigna of CA HMO |
$6.96
|
| Rate for Payer: Cigna of CA PPO |
$6.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.45
|
| Rate for Payer: Dignity Health Media |
$8.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.98
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.98
|
| Rate for Payer: Galaxy Health WC |
$8.45
|
| Rate for Payer: Global Benefits Group Commercial |
$5.96
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$7.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.39
|
| Rate for Payer: Multiplan Commercial |
$7.95
|
| Rate for Payer: Networks By Design Commercial |
$6.46
|
| Rate for Payer: Prime Health Services Commercial |
$8.45
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.97
|
| Rate for Payer: United Healthcare All Other HMO |
$4.97
|
| Rate for Payer: United Healthcare HMO Rider |
$4.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.45
|
| Rate for Payer: Vantage Medical Group Senior |
$8.45
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
IP
|
$7.14
|
|
|
Service Code
|
NDC 0378-6612-93
|
| Hospital Charge Code |
1710827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Blue Shield of California Commercial |
$5.08
|
| Rate for Payer: Blue Shield of California EPN |
$3.66
|
| Rate for Payer: Cash Price |
$3.21
|
| Rate for Payer: Cigna of CA HMO |
$5.00
|
| Rate for Payer: Cigna of CA PPO |
$5.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.86
|
| Rate for Payer: Galaxy Health WC |
$6.07
|
| Rate for Payer: Global Benefits Group Commercial |
$4.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.71
|
| Rate for Payer: Multiplan Commercial |
$5.71
|
| Rate for Payer: Networks By Design Commercial |
$4.64
|
| Rate for Payer: Prime Health Services Commercial |
$6.07
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
OP
|
$16.83
|
|
|
Service Code
|
NDC 0555-1055-56
|
| Hospital Charge Code |
1710827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.04 |
| Max. Negotiated Rate |
$14.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.03
|
| Rate for Payer: BCBS Transplant Transplant |
$10.10
|
| Rate for Payer: Blue Shield of California Commercial |
$12.40
|
| Rate for Payer: Blue Shield of California EPN |
$9.83
|
| Rate for Payer: Cash Price |
$7.57
|
| Rate for Payer: Cigna of CA HMO |
$11.78
|
| Rate for Payer: Cigna of CA PPO |
$11.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.31
|
| Rate for Payer: Dignity Health Media |
$14.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.73
|
| Rate for Payer: Galaxy Health WC |
$14.31
|
| Rate for Payer: Global Benefits Group Commercial |
$10.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$12.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.04
|
| Rate for Payer: Multiplan Commercial |
$13.46
|
| Rate for Payer: Networks By Design Commercial |
$10.94
|
| Rate for Payer: Prime Health Services Commercial |
$14.31
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$10.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.42
|
| Rate for Payer: United Healthcare All Other HMO |
$8.42
|
| Rate for Payer: United Healthcare HMO Rider |
$8.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.31
|
| Rate for Payer: Vantage Medical Group Senior |
$14.31
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
IP
|
$9.94
|
|
|
Service Code
|
NDC 61748-302-11
|
| Hospital Charge Code |
1710827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$8.45 |
| Rate for Payer: Blue Shield of California Commercial |
$7.08
|
| Rate for Payer: Blue Shield of California EPN |
$5.09
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Cigna of CA HMO |
$6.96
|
| Rate for Payer: Cigna of CA PPO |
$6.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.98
|
| Rate for Payer: Galaxy Health WC |
$8.45
|
| Rate for Payer: Global Benefits Group Commercial |
$5.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.39
|
| Rate for Payer: Multiplan Commercial |
$7.95
|
| Rate for Payer: Networks By Design Commercial |
$6.46
|
| Rate for Payer: Prime Health Services Commercial |
$8.45
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
IP
|
$16.83
|
|
|
Service Code
|
NDC 0555-1055-56
|
| Hospital Charge Code |
1710827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.04 |
| Max. Negotiated Rate |
$14.31 |
| Rate for Payer: Blue Shield of California Commercial |
$11.98
|
| Rate for Payer: Blue Shield of California EPN |
$8.62
|
| Rate for Payer: Cash Price |
$7.57
|
| Rate for Payer: Cigna of CA HMO |
$11.78
|
| Rate for Payer: Cigna of CA PPO |
$11.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.73
|
| Rate for Payer: Galaxy Health WC |
$14.31
|
| Rate for Payer: Global Benefits Group Commercial |
$10.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.04
|
| Rate for Payer: Multiplan Commercial |
$13.46
|
| Rate for Payer: Networks By Design Commercial |
$10.94
|
| Rate for Payer: Prime Health Services Commercial |
$14.31
|
|
|
ISOTRETINOIN 40 MG CAPSULE [10361]
|
Facility
IP
|
$11.84
|
|
|
Service Code
|
NDC 61748-304-13
|
| Hospital Charge Code |
1710009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$10.06 |
| Rate for Payer: Blue Shield of California Commercial |
$8.43
|
| Rate for Payer: Blue Shield of California EPN |
$6.06
|
| Rate for Payer: Cash Price |
$5.33
|
| Rate for Payer: Cigna of CA HMO |
$8.29
|
| Rate for Payer: Cigna of CA PPO |
$8.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.74
|
| Rate for Payer: Galaxy Health WC |
$10.06
|
| Rate for Payer: Global Benefits Group Commercial |
$7.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$9.47
|
| Rate for Payer: Networks By Design Commercial |
$7.70
|
| Rate for Payer: Prime Health Services Commercial |
$10.06
|
|
|
ISOTRETINOIN 40 MG CAPSULE [10361]
|
Facility
OP
|
$11.84
|
|
|
Service Code
|
NDC 61748-304-13
|
| Hospital Charge Code |
1710009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$10.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.05
|
| Rate for Payer: BCBS Transplant Transplant |
$7.10
|
| Rate for Payer: Blue Shield of California Commercial |
$8.73
|
| Rate for Payer: Blue Shield of California EPN |
$6.91
|
| Rate for Payer: Cash Price |
$5.33
|
| Rate for Payer: Cigna of CA HMO |
$8.29
|
| Rate for Payer: Cigna of CA PPO |
$8.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.06
|
| Rate for Payer: Dignity Health Media |
$10.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.74
|
| Rate for Payer: Galaxy Health WC |
$10.06
|
| Rate for Payer: Global Benefits Group Commercial |
$7.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$9.47
|
| Rate for Payer: Networks By Design Commercial |
$7.70
|
| Rate for Payer: Prime Health Services Commercial |
$10.06
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$7.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.92
|
| Rate for Payer: United Healthcare All Other HMO |
$5.92
|
| Rate for Payer: United Healthcare HMO Rider |
$5.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.06
|
| Rate for Payer: Vantage Medical Group Senior |
$10.06
|
|
|
ISOTRETINOIN 40 MG CAPSULE [10361]
|
Facility
OP
|
$8.30
|
|
|
Service Code
|
NDC 0378-6614-93
|
| Hospital Charge Code |
1710009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$7.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.95
|
| Rate for Payer: BCBS Transplant Transplant |
$4.98
|
| Rate for Payer: Blue Shield of California Commercial |
$6.12
|
| Rate for Payer: Blue Shield of California EPN |
$4.85
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Cigna of CA HMO |
$5.81
|
| Rate for Payer: Cigna of CA PPO |
$5.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.06
|
| Rate for Payer: Dignity Health Media |
$7.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.32
|
| Rate for Payer: Galaxy Health WC |
$7.06
|
| Rate for Payer: Global Benefits Group Commercial |
$4.98
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.99
|
| Rate for Payer: Multiplan Commercial |
$6.64
|
| Rate for Payer: Networks By Design Commercial |
$5.40
|
| Rate for Payer: Prime Health Services Commercial |
$7.06
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Other HMO |
$4.15
|
| Rate for Payer: United Healthcare HMO Rider |
$4.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.06
|
| Rate for Payer: Vantage Medical Group Senior |
$7.06
|
|
|
ISOTRETINOIN 40 MG CAPSULE [10361]
|
Facility
IP
|
$8.30
|
|
|
Service Code
|
NDC 0378-6614-93
|
| Hospital Charge Code |
1710009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$7.06 |
| Rate for Payer: Blue Shield of California Commercial |
$5.91
|
| Rate for Payer: Blue Shield of California EPN |
$4.25
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Cigna of CA HMO |
$5.81
|
| Rate for Payer: Cigna of CA PPO |
$5.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.32
|
| Rate for Payer: Galaxy Health WC |
$7.06
|
| Rate for Payer: Global Benefits Group Commercial |
$4.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.99
|
| Rate for Payer: Multiplan Commercial |
$6.64
|
| Rate for Payer: Networks By Design Commercial |
$5.40
|
| Rate for Payer: Prime Health Services Commercial |
$7.06
|
|
|
ISRADIPINE 2.5 MG CAPSULE [10362]
|
Facility
OP
|
$1.73
|
|
|
Service Code
|
NDC 16252-539-01
|
| Hospital Charge Code |
1711608
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.03
|
| Rate for Payer: BCBS Transplant Transplant |
$1.04
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.01
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna of CA HMO |
$1.21
|
| Rate for Payer: Cigna of CA PPO |
$1.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.47
|
| Rate for Payer: Dignity Health Media |
$1.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.69
|
| Rate for Payer: Galaxy Health WC |
$1.47
|
| Rate for Payer: Global Benefits Group Commercial |
$1.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.38
|
| Rate for Payer: Networks By Design Commercial |
$1.12
|
| Rate for Payer: Prime Health Services Commercial |
$1.47
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.87
|
| Rate for Payer: United Healthcare All Other HMO |
$0.87
|
| Rate for Payer: United Healthcare HMO Rider |
$0.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.47
|
| Rate for Payer: Vantage Medical Group Senior |
$1.47
|
|
|
ISRADIPINE 2.5 MG CAPSULE [10362]
|
Facility
IP
|
$1.73
|
|
|
Service Code
|
NDC 16252-539-01
|
| Hospital Charge Code |
1711608
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: Blue Shield of California Commercial |
$1.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.89
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna of CA HMO |
$1.21
|
| Rate for Payer: Cigna of CA PPO |
$1.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Galaxy Health WC |
$1.47
|
| Rate for Payer: Global Benefits Group Commercial |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.38
|
| Rate for Payer: Networks By Design Commercial |
$1.12
|
| Rate for Payer: Prime Health Services Commercial |
$1.47
|
|
|
ISRADIPINE ORAL SUSPENSION COMPOUND 1 MG/ML [4080283]
|
Facility
OP
|
$0.40
|
|
|
Service Code
|
NDC 9994-0802-83
|
| Hospital Charge Code |
1715228
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: BCBS Transplant Transplant |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Media |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
ISRADIPINE ORAL SUSPENSION COMPOUND 1 MG/ML [4080283]
|
Facility
IP
|
$0.40
|
|
|
Service Code
|
NDC 9994-0802-83
|
| Hospital Charge Code |
1715228
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
OP
|
$8.93
|
|
|
Service Code
|
NDC 10147-1700-7
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$7.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.32
|
| Rate for Payer: BCBS Transplant Transplant |
$5.36
|
| Rate for Payer: Blue Shield of California Commercial |
$6.58
|
| Rate for Payer: Blue Shield of California EPN |
$5.22
|
| Rate for Payer: Cash Price |
$4.02
|
| Rate for Payer: Cigna of CA HMO |
$6.25
|
| Rate for Payer: Cigna of CA PPO |
$6.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.59
|
| Rate for Payer: Dignity Health Media |
$7.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.57
|
| Rate for Payer: Galaxy Health WC |
$7.59
|
| Rate for Payer: Global Benefits Group Commercial |
$5.36
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$7.14
|
| Rate for Payer: Networks By Design Commercial |
$5.80
|
| Rate for Payer: Prime Health Services Commercial |
$7.59
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Other HMO |
$4.46
|
| Rate for Payer: United Healthcare HMO Rider |
$4.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7.59
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
OP
|
$2.00
|
|
|
Service Code
|
NDC 49884-239-11
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.19
|
| Rate for Payer: BCBS Transplant Transplant |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$1.47
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO |
$1.40
|
| Rate for Payer: Cigna of CA PPO |
$1.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Media |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Networks By Design Commercial |
$1.30
|
| Rate for Payer: Prime Health Services Commercial |
$1.70
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.70
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
IP
|
$2.00
|
|
|
Service Code
|
NDC 67877-454-30
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.02
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO |
$1.40
|
| Rate for Payer: Cigna of CA PPO |
$1.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Networks By Design Commercial |
$1.30
|
| Rate for Payer: Prime Health Services Commercial |
$1.70
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
OP
|
$15.10
|
|
|
Service Code
|
NDC 0378-5100-93
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$12.84 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.00
|
| Rate for Payer: BCBS Transplant Transplant |
$9.06
|
| Rate for Payer: Blue Shield of California Commercial |
$11.13
|
| Rate for Payer: Blue Shield of California EPN |
$8.82
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: Cigna of CA HMO |
$10.57
|
| Rate for Payer: Cigna of CA PPO |
$10.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.84
|
| Rate for Payer: Dignity Health Media |
$12.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.04
|
| Rate for Payer: Galaxy Health WC |
$12.84
|
| Rate for Payer: Global Benefits Group Commercial |
$9.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$11.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.62
|
| Rate for Payer: Multiplan Commercial |
$12.08
|
| Rate for Payer: Networks By Design Commercial |
$9.82
|
| Rate for Payer: Prime Health Services Commercial |
$12.84
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$9.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.55
|
| Rate for Payer: United Healthcare All Other HMO |
$7.55
|
| Rate for Payer: United Healthcare HMO Rider |
$7.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.84
|
| Rate for Payer: Vantage Medical Group Senior |
$12.84
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
IP
|
$15.10
|
|
|
Service Code
|
NDC 0378-5100-93
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$12.84 |
| Rate for Payer: Blue Shield of California Commercial |
$10.75
|
| Rate for Payer: Blue Shield of California EPN |
$7.73
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: Cigna of CA HMO |
$10.57
|
| Rate for Payer: Cigna of CA PPO |
$10.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.04
|
| Rate for Payer: Galaxy Health WC |
$12.84
|
| Rate for Payer: Global Benefits Group Commercial |
$9.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.62
|
| Rate for Payer: Multiplan Commercial |
$12.08
|
| Rate for Payer: Networks By Design Commercial |
$9.82
|
| Rate for Payer: Prime Health Services Commercial |
$12.84
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
OP
|
$33.78
|
|
|
Service Code
|
NDC 50458-290-01
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.11 |
| Max. Negotiated Rate |
$28.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$22.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.13
|
| Rate for Payer: BCBS Transplant Transplant |
$20.27
|
| Rate for Payer: Blue Shield of California Commercial |
$24.90
|
| Rate for Payer: Blue Shield of California EPN |
$19.73
|
| Rate for Payer: Cash Price |
$15.20
|
| Rate for Payer: Cigna of CA HMO |
$23.65
|
| Rate for Payer: Cigna of CA PPO |
$23.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.71
|
| Rate for Payer: Dignity Health Media |
$28.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.51
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.51
|
| Rate for Payer: Galaxy Health WC |
$28.71
|
| Rate for Payer: Global Benefits Group Commercial |
$20.27
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$25.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.11
|
| Rate for Payer: Multiplan Commercial |
$27.02
|
| Rate for Payer: Networks By Design Commercial |
$21.96
|
| Rate for Payer: Prime Health Services Commercial |
$28.71
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$20.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.89
|
| Rate for Payer: United Healthcare All Other HMO |
$16.89
|
| Rate for Payer: United Healthcare HMO Rider |
$16.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.71
|
| Rate for Payer: Vantage Medical Group Senior |
$28.71
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
IP
|
$2.00
|
|
|
Service Code
|
NDC 65162-630-03
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.02
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO |
$1.40
|
| Rate for Payer: Cigna of CA PPO |
$1.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Networks By Design Commercial |
$1.30
|
| Rate for Payer: Prime Health Services Commercial |
$1.70
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
IP
|
$2.00
|
|
|
Service Code
|
NDC 49884-239-11
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.02
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO |
$1.40
|
| Rate for Payer: Cigna of CA PPO |
$1.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Networks By Design Commercial |
$1.30
|
| Rate for Payer: Prime Health Services Commercial |
$1.70
|
|
