|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
IP
|
$0.22
|
|
|
Service Code
|
NDC 68084-318-11
|
| Hospital Charge Code |
1711638
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
NDC 51672-4130-1
|
| Hospital Charge Code |
1711638
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 13668-045-01
|
| Hospital Charge Code |
1711638
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: BCBS Transplant Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Media |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
IP
|
$9.13
|
|
|
Service Code
|
NDC 0115-9940-68
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Blue Shield of California Commercial |
$6.50
|
| Rate for Payer: Blue Shield of California EPN |
$4.67
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Cigna of CA HMO |
$6.39
|
| Rate for Payer: Cigna of CA PPO |
$6.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.65
|
| Rate for Payer: Galaxy Health WC |
$7.76
|
| Rate for Payer: Global Benefits Group Commercial |
$5.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Multiplan Commercial |
$7.30
|
| Rate for Payer: Networks By Design Commercial |
$5.93
|
| Rate for Payer: Prime Health Services Commercial |
$7.76
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
IP
|
$9.13
|
|
|
Service Code
|
NDC 49884-485-54
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Blue Shield of California Commercial |
$6.50
|
| Rate for Payer: Blue Shield of California EPN |
$4.67
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Cigna of CA HMO |
$6.39
|
| Rate for Payer: Cigna of CA PPO |
$6.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.65
|
| Rate for Payer: Galaxy Health WC |
$7.76
|
| Rate for Payer: Global Benefits Group Commercial |
$5.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Multiplan Commercial |
$7.30
|
| Rate for Payer: Networks By Design Commercial |
$5.93
|
| Rate for Payer: Prime Health Services Commercial |
$7.76
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
OP
|
$9.13
|
|
|
Service Code
|
NDC 0115-9940-68
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.44
|
| Rate for Payer: BCBS Transplant Transplant |
$5.48
|
| Rate for Payer: Blue Shield of California Commercial |
$6.73
|
| Rate for Payer: Blue Shield of California EPN |
$5.33
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Cigna of CA HMO |
$6.39
|
| Rate for Payer: Cigna of CA PPO |
$6.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.76
|
| Rate for Payer: Dignity Health Media |
$7.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.65
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.65
|
| Rate for Payer: Galaxy Health WC |
$7.76
|
| Rate for Payer: Global Benefits Group Commercial |
$5.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Multiplan Commercial |
$7.30
|
| Rate for Payer: Networks By Design Commercial |
$5.93
|
| Rate for Payer: Prime Health Services Commercial |
$7.76
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Other HMO |
$4.56
|
| Rate for Payer: United Healthcare HMO Rider |
$4.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.76
|
| Rate for Payer: Vantage Medical Group Senior |
$7.76
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
OP
|
$9.13
|
|
|
Service Code
|
NDC 49884-485-54
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.44
|
| Rate for Payer: BCBS Transplant Transplant |
$5.48
|
| Rate for Payer: Blue Shield of California Commercial |
$6.73
|
| Rate for Payer: Blue Shield of California EPN |
$5.33
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Cigna of CA HMO |
$6.39
|
| Rate for Payer: Cigna of CA PPO |
$6.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.76
|
| Rate for Payer: Dignity Health Media |
$7.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.65
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.65
|
| Rate for Payer: Galaxy Health WC |
$7.76
|
| Rate for Payer: Global Benefits Group Commercial |
$5.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Multiplan Commercial |
$7.30
|
| Rate for Payer: Networks By Design Commercial |
$5.93
|
| Rate for Payer: Prime Health Services Commercial |
$7.76
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Other HMO |
$4.56
|
| Rate for Payer: United Healthcare HMO Rider |
$4.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.76
|
| Rate for Payer: Vantage Medical Group Senior |
$7.76
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
IP
|
$6.36
|
|
|
Service Code
|
NDC 27241-184-30
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$5.41 |
| Rate for Payer: Blue Shield of California Commercial |
$4.53
|
| Rate for Payer: Blue Shield of California EPN |
$3.26
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cigna of CA HMO |
$4.45
|
| Rate for Payer: Cigna of CA PPO |
$4.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: Galaxy Health WC |
$5.41
|
| Rate for Payer: Global Benefits Group Commercial |
$3.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$5.09
|
| Rate for Payer: Networks By Design Commercial |
$4.13
|
| Rate for Payer: Prime Health Services Commercial |
$5.41
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
OP
|
$9.13
|
|
|
Service Code
|
NDC 49884-485-11
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.76
|
| Rate for Payer: Vantage Medical Group Senior |
$7.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.44
|
| Rate for Payer: BCBS Transplant Transplant |
$5.48
|
| Rate for Payer: Blue Shield of California Commercial |
$6.73
|
| Rate for Payer: Blue Shield of California EPN |
$5.33
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Cigna of CA HMO |
$6.39
|
| Rate for Payer: Cigna of CA PPO |
$6.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.76
|
| Rate for Payer: Dignity Health Media |
$7.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.65
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.65
|
| Rate for Payer: Galaxy Health WC |
$7.76
|
| Rate for Payer: Global Benefits Group Commercial |
$5.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Multiplan Commercial |
$7.30
|
| Rate for Payer: Networks By Design Commercial |
$5.93
|
| Rate for Payer: Prime Health Services Commercial |
$7.76
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Other HMO |
$4.56
|
| Rate for Payer: United Healthcare HMO Rider |
$4.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.76
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
IP
|
$9.13
|
|
|
Service Code
|
NDC 49884-485-11
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Blue Shield of California Commercial |
$6.50
|
| Rate for Payer: Blue Shield of California EPN |
$4.67
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Cigna of CA HMO |
$6.39
|
| Rate for Payer: Cigna of CA PPO |
$6.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.65
|
| Rate for Payer: Galaxy Health WC |
$7.76
|
| Rate for Payer: Global Benefits Group Commercial |
$5.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Multiplan Commercial |
$7.30
|
| Rate for Payer: Networks By Design Commercial |
$5.93
|
| Rate for Payer: Prime Health Services Commercial |
$7.76
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
OP
|
$6.36
|
|
|
Service Code
|
NDC 27241-184-30
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$5.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.79
|
| Rate for Payer: BCBS Transplant Transplant |
$3.82
|
| Rate for Payer: Blue Shield of California Commercial |
$4.69
|
| Rate for Payer: Blue Shield of California EPN |
$3.71
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cigna of CA HMO |
$4.45
|
| Rate for Payer: Cigna of CA PPO |
$4.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.41
|
| Rate for Payer: Dignity Health Media |
$5.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.54
|
| Rate for Payer: Galaxy Health WC |
$5.41
|
| Rate for Payer: Global Benefits Group Commercial |
$3.82
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$5.09
|
| Rate for Payer: Networks By Design Commercial |
$4.13
|
| Rate for Payer: Prime Health Services Commercial |
$5.41
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.18
|
| Rate for Payer: United Healthcare All Other HMO |
$3.18
|
| Rate for Payer: United Healthcare HMO Rider |
$3.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.41
|
| Rate for Payer: Vantage Medical Group Senior |
$5.41
|
|
|
LAMOTRIGINE 5 MG CHEWABLE DISPERSIBLE TABLET [104568]
|
Facility
IP
|
$18.48
|
|
|
Service Code
|
NDC 0173-0526-00
|
| Hospital Charge Code |
1711792
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Blue Shield of California Commercial |
$13.16
|
| Rate for Payer: Blue Shield of California EPN |
$9.46
|
| Rate for Payer: Cash Price |
$8.32
|
| Rate for Payer: Cigna of CA HMO |
$12.94
|
| Rate for Payer: Cigna of CA PPO |
$12.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.39
|
| Rate for Payer: Galaxy Health WC |
$15.71
|
| Rate for Payer: Global Benefits Group Commercial |
$11.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.44
|
| Rate for Payer: Multiplan Commercial |
$14.78
|
| Rate for Payer: Networks By Design Commercial |
$12.01
|
| Rate for Payer: Prime Health Services Commercial |
$15.71
|
|
|
LAMOTRIGINE 5 MG CHEWABLE DISPERSIBLE TABLET [104568]
|
Facility
OP
|
$18.48
|
|
|
Service Code
|
NDC 0173-0526-00
|
| Hospital Charge Code |
1711792
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$15.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.01
|
| Rate for Payer: BCBS Transplant Transplant |
$11.09
|
| Rate for Payer: Blue Shield of California Commercial |
$13.62
|
| Rate for Payer: Blue Shield of California EPN |
$10.79
|
| Rate for Payer: Cash Price |
$8.32
|
| Rate for Payer: Cigna of CA HMO |
$12.94
|
| Rate for Payer: Cigna of CA PPO |
$12.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.71
|
| Rate for Payer: Dignity Health Media |
$15.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.39
|
| Rate for Payer: Galaxy Health WC |
$15.71
|
| Rate for Payer: Global Benefits Group Commercial |
$11.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$13.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.44
|
| Rate for Payer: Multiplan Commercial |
$14.78
|
| Rate for Payer: Networks By Design Commercial |
$12.01
|
| Rate for Payer: Prime Health Services Commercial |
$15.71
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$11.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.24
|
| Rate for Payer: United Healthcare All Other HMO |
$9.24
|
| Rate for Payer: United Healthcare HMO Rider |
$9.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.71
|
| Rate for Payer: Vantage Medical Group Senior |
$15.71
|
|
|
LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM [120012]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
NDC 7214000022
|
| Hospital Charge Code |
NDG11371C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM [120012]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 7214000022
|
| Hospital Charge Code |
NDG11371C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: BCBS Transplant Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Media |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM [120012]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 7214003868
|
| Hospital Charge Code |
NDG11371B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
|
|
LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM [120012]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 7214003868
|
| Hospital Charge Code |
NDG11371B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: BCBS Transplant Transplant |
$0.05
|
| 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 |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Media |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| 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 |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
LANOLIN-MINERAL OIL LOTION [2787]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 7214011019
|
| Hospital Charge Code |
NDG2787
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: BCBS Transplant Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
LANOLIN-MINERAL OIL LOTION [2787]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 7214011019
|
| Hospital Charge Code |
NDG2787
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
LANREOTIDE 60 MG/0.2 ML SUBCUTANEOUS SYRINGE [88570]
|
Facility
OP
|
$36,528.00
|
|
|
Service Code
|
CPT J1930
|
| Hospital Charge Code |
ERX88570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.44 |
| Max. Negotiated Rate |
$31,048.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$304.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$60.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$53.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$53.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$55.81
|
| Rate for Payer: BCBS Transplant Transplant |
$21,916.80
|
| Rate for Payer: Blue Shield of California Commercial |
$26,921.14
|
| Rate for Payer: Blue Shield of California EPN |
$99.00
|
| Rate for Payer: Cash Price |
$16,437.60
|
| Rate for Payer: Cash Price |
$16,437.60
|
| Rate for Payer: Cigna of CA HMO |
$25,569.60
|
| Rate for Payer: Cigna of CA PPO |
$25,569.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.66
|
| Rate for Payer: Dignity Health Media |
$48.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.40
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$48.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.44
|
| Rate for Payer: Galaxy Health WC |
$31,048.80
|
| Rate for Payer: Global Benefits Group Commercial |
$21,916.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$27,396.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.45
|
| Rate for Payer: Heritage Provider Network Transplant |
$79.45
|
| Rate for Payer: IEHP Medi-Cal |
$78.48
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$78.48
|
| Rate for Payer: IEHP Medicare Advantage |
$48.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24,364.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$100.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$48.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8,766.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$61.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$64.91
|
| Rate for Payer: Multiplan Commercial |
$29,222.40
|
| Rate for Payer: Networks By Design Commercial |
$18,264.00
|
| Rate for Payer: Prime Health Services Commercial |
$31,048.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21,916.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21,916.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$18,264.00
|
| Rate for Payer: United Healthcare All Other HMO |
$18,264.00
|
| Rate for Payer: United Healthcare HMO Rider |
$18,264.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18,264.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.29
|
| Rate for Payer: Vantage Medical Group Senior |
$48.44
|
|
|
LANREOTIDE 60 MG/0.2 ML SUBCUTANEOUS SYRINGE [88570]
|
Facility
IP
|
$36,528.00
|
|
|
Service Code
|
CPT J1930
|
| Hospital Charge Code |
ERX88570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,766.72 |
| Max. Negotiated Rate |
$31,048.80 |
| Rate for Payer: Blue Shield of California Commercial |
$26,007.94
|
| Rate for Payer: Blue Shield of California EPN |
$18,702.34
|
| Rate for Payer: Cash Price |
$16,437.60
|
| Rate for Payer: Cigna of CA HMO |
$25,569.60
|
| Rate for Payer: Cigna of CA PPO |
$25,569.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$14,611.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$14,611.20
|
| Rate for Payer: Galaxy Health WC |
$31,048.80
|
| Rate for Payer: Global Benefits Group Commercial |
$21,916.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24,364.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,917.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8,766.72
|
| Rate for Payer: Multiplan Commercial |
$29,222.40
|
| Rate for Payer: Networks By Design Commercial |
$18,264.00
|
| Rate for Payer: Prime Health Services Commercial |
$31,048.80
|
|
|
LANREOTIDE 90 MG/0.3 ML SUBCUTANEOUS SYRINGE [87860]
|
Facility
IP
|
$32,432.00
|
|
|
Service Code
|
CPT J1930
|
| Hospital Charge Code |
NDG87860
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,783.68 |
| Max. Negotiated Rate |
$27,567.20 |
| Rate for Payer: Blue Shield of California Commercial |
$23,091.58
|
| Rate for Payer: Blue Shield of California EPN |
$16,605.18
|
| Rate for Payer: Cash Price |
$14,594.40
|
| Rate for Payer: Cigna of CA HMO |
$22,702.40
|
| Rate for Payer: Cigna of CA PPO |
$22,702.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,972.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$12,972.80
|
| Rate for Payer: Galaxy Health WC |
$27,567.20
|
| Rate for Payer: Global Benefits Group Commercial |
$19,459.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21,632.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,356.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,783.68
|
| Rate for Payer: Multiplan Commercial |
$25,945.60
|
| Rate for Payer: Networks By Design Commercial |
$16,216.00
|
| Rate for Payer: Prime Health Services Commercial |
$27,567.20
|
|
|
LANREOTIDE 90 MG/0.3 ML SUBCUTANEOUS SYRINGE [87860]
|
Facility
OP
|
$32,432.00
|
|
|
Service Code
|
CPT J1930
|
| Hospital Charge Code |
NDG87860
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.44 |
| Max. Negotiated Rate |
$27,567.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$304.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$60.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$53.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$53.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$55.81
|
| Rate for Payer: BCBS Transplant Transplant |
$19,459.20
|
| Rate for Payer: Blue Shield of California Commercial |
$23,902.38
|
| Rate for Payer: Blue Shield of California EPN |
$99.00
|
| Rate for Payer: Cash Price |
$14,594.40
|
| Rate for Payer: Cash Price |
$14,594.40
|
| Rate for Payer: Cigna of CA HMO |
$22,702.40
|
| Rate for Payer: Cigna of CA PPO |
$22,702.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.66
|
| Rate for Payer: Dignity Health Media |
$48.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.40
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$48.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.44
|
| Rate for Payer: Galaxy Health WC |
$27,567.20
|
| Rate for Payer: Global Benefits Group Commercial |
$19,459.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$24,324.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.45
|
| Rate for Payer: Heritage Provider Network Transplant |
$79.45
|
| Rate for Payer: IEHP Medi-Cal |
$78.48
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$78.48
|
| Rate for Payer: IEHP Medicare Advantage |
$48.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21,632.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$100.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$48.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,783.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$61.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$64.91
|
| Rate for Payer: Multiplan Commercial |
$25,945.60
|
| Rate for Payer: Networks By Design Commercial |
$16,216.00
|
| Rate for Payer: Prime Health Services Commercial |
$27,567.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$19,459.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$19,459.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$16,216.00
|
| Rate for Payer: United Healthcare All Other HMO |
$16,216.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,216.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16,216.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.29
|
| Rate for Payer: Vantage Medical Group Senior |
$48.44
|
|
|
LANSOPRAZOLE 15 MG CAPSULE,DELAYED RELEASE [27691]
|
Facility
OP
|
$3.65
|
|
|
Service Code
|
NDC 60687-111-21
|
| Hospital Charge Code |
1711714
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Galaxy Health WC |
$3.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.17
|
| Rate for Payer: BCBS Transplant Transplant |
$2.19
|
| Rate for Payer: Blue Shield of California Commercial |
$2.69
|
| Rate for Payer: Blue Shield of California EPN |
$2.13
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: Cigna of CA HMO |
$2.56
|
| Rate for Payer: Cigna of CA PPO |
$2.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.10
|
| Rate for Payer: Dignity Health Media |
$3.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.46
|
| Rate for Payer: Global Benefits Group Commercial |
$2.19
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
| Rate for Payer: Networks By Design Commercial |
$2.37
|
| Rate for Payer: Prime Health Services Commercial |
$3.10
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.82
|
| Rate for Payer: United Healthcare All Other HMO |
$1.82
|
| Rate for Payer: United Healthcare HMO Rider |
$1.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.10
|
| Rate for Payer: Vantage Medical Group Senior |
$3.10
|
|
|
LANSOPRAZOLE 15 MG CAPSULE,DELAYED RELEASE [27691]
|
Facility
IP
|
$3.65
|
|
|
Service Code
|
NDC 60687-111-21
|
| Hospital Charge Code |
1711714
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Blue Shield of California Commercial |
$2.60
|
| Rate for Payer: Blue Shield of California EPN |
$1.87
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: Cigna of CA HMO |
$2.56
|
| Rate for Payer: Cigna of CA PPO |
$2.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: Galaxy Health WC |
$3.10
|
| Rate for Payer: Global Benefits Group Commercial |
$2.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
| Rate for Payer: Networks By Design Commercial |
$2.37
|
| Rate for Payer: Prime Health Services Commercial |
$3.10
|
|
