|
CANNABIDIOL 100 MG/ML ORAL SOLUTION [222792]
|
Facility
|
IP
|
$18.84
|
|
|
Service Code
|
NDC 70127-100-01
|
| Hospital Charge Code |
NDG22792
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$16.01 |
| Rate for Payer: Blue Shield of California Commercial |
$13.41
|
| Rate for Payer: Blue Shield of California EPN |
$9.65
|
| Rate for Payer: Cash Price |
$8.48
|
| Rate for Payer: Cigna of CA HMO |
$13.19
|
| Rate for Payer: Cigna of CA PPO |
$13.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.54
|
| Rate for Payer: Galaxy Health WC |
$16.01
|
| Rate for Payer: Global Benefits Group Commercial |
$11.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.52
|
| Rate for Payer: Multiplan Commercial |
$15.07
|
| Rate for Payer: Networks By Design Commercial |
$12.25
|
| Rate for Payer: Prime Health Services Commercial |
$16.01
|
|
|
CANNABIDIOL 100 MG/ML ORAL SOLUTION [222792]
|
Facility
|
OP
|
$18.84
|
|
|
Service Code
|
NDC 70127-100-10
|
| Hospital Charge Code |
NDG22792
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$16.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.22
|
| Rate for Payer: Blue Distinction Transplant |
$11.30
|
| Rate for Payer: Blue Shield of California Commercial |
$13.89
|
| Rate for Payer: Blue Shield of California EPN |
$11.00
|
| Rate for Payer: Cash Price |
$8.48
|
| Rate for Payer: Cigna of CA HMO |
$13.19
|
| Rate for Payer: Cigna of CA PPO |
$13.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.01
|
| Rate for Payer: Dignity Health Media |
$16.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.54
|
| Rate for Payer: Galaxy Health WC |
$16.01
|
| Rate for Payer: Global Benefits Group Commercial |
$11.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$14.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.52
|
| Rate for Payer: Multiplan Commercial |
$15.07
|
| Rate for Payer: Networks By Design Commercial |
$12.25
|
| Rate for Payer: Prime Health Services Commercial |
$16.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.42
|
| Rate for Payer: United Healthcare All Other HMO |
$9.42
|
| Rate for Payer: United Healthcare HMO Rider |
$9.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.01
|
| Rate for Payer: Vantage Medical Group Senior |
$16.01
|
|
|
CANNABIDIOL 100 MG/ML ORAL SOLUTION [222792]
|
Facility
|
IP
|
$18.84
|
|
|
Service Code
|
NDC 70127-100-10
|
| Hospital Charge Code |
NDG22792
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$16.01 |
| Rate for Payer: Blue Shield of California Commercial |
$13.41
|
| Rate for Payer: Blue Shield of California EPN |
$9.65
|
| Rate for Payer: Cash Price |
$8.48
|
| Rate for Payer: Cigna of CA HMO |
$13.19
|
| Rate for Payer: Cigna of CA PPO |
$13.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.54
|
| Rate for Payer: Galaxy Health WC |
$16.01
|
| Rate for Payer: Global Benefits Group Commercial |
$11.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.52
|
| Rate for Payer: Multiplan Commercial |
$15.07
|
| Rate for Payer: Networks By Design Commercial |
$12.25
|
| Rate for Payer: Prime Health Services Commercial |
$16.01
|
|
|
CANNABIDIOL 100 MG/ML ORAL SOLUTION [222792]
|
Facility
|
OP
|
$18.84
|
|
|
Service Code
|
NDC 70127-100-01
|
| Hospital Charge Code |
NDG22792
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$16.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.22
|
| Rate for Payer: Blue Distinction Transplant |
$11.30
|
| Rate for Payer: Blue Shield of California Commercial |
$13.89
|
| Rate for Payer: Blue Shield of California EPN |
$11.00
|
| Rate for Payer: Cash Price |
$8.48
|
| Rate for Payer: Cigna of CA HMO |
$13.19
|
| Rate for Payer: Cigna of CA PPO |
$13.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.01
|
| Rate for Payer: Dignity Health Media |
$16.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.54
|
| Rate for Payer: Galaxy Health WC |
$16.01
|
| Rate for Payer: Global Benefits Group Commercial |
$11.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$14.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.52
|
| Rate for Payer: Multiplan Commercial |
$15.07
|
| Rate for Payer: Networks By Design Commercial |
$12.25
|
| Rate for Payer: Prime Health Services Commercial |
$16.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.42
|
| Rate for Payer: United Healthcare All Other HMO |
$9.42
|
| Rate for Payer: United Healthcare HMO Rider |
$9.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.01
|
| Rate for Payer: Vantage Medical Group Senior |
$16.01
|
|
|
CAPMATINIB 150 MG TABLET [228060]
|
Facility
|
OP
|
$231.18
|
|
|
Service Code
|
NDC 0078-0709-56
|
| Hospital Charge Code |
ERX228060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.48 |
| Max. Negotiated Rate |
$196.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$151.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$196.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$127.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$127.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$137.74
|
| Rate for Payer: Blue Distinction Transplant |
$138.71
|
| Rate for Payer: Blue Shield of California Commercial |
$170.38
|
| Rate for Payer: Blue Shield of California EPN |
$135.01
|
| Rate for Payer: Cash Price |
$104.03
|
| Rate for Payer: Cigna of CA HMO |
$161.83
|
| Rate for Payer: Cigna of CA PPO |
$161.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$196.50
|
| Rate for Payer: Dignity Health Media |
$196.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$196.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$92.47
|
| Rate for Payer: Galaxy Health WC |
$196.50
|
| Rate for Payer: Global Benefits Group Commercial |
$138.71
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$173.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$154.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.48
|
| Rate for Payer: Multiplan Commercial |
$184.94
|
| Rate for Payer: Networks By Design Commercial |
$150.27
|
| Rate for Payer: Prime Health Services Commercial |
$196.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$138.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$138.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$115.59
|
| Rate for Payer: United Healthcare All Other HMO |
$115.59
|
| Rate for Payer: United Healthcare HMO Rider |
$115.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$115.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$196.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$196.50
|
| Rate for Payer: Vantage Medical Group Senior |
$196.50
|
|
|
CAPMATINIB 150 MG TABLET [228060]
|
Facility
|
IP
|
$231.18
|
|
|
Service Code
|
NDC 0078-0709-56
|
| Hospital Charge Code |
ERX228060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.48 |
| Max. Negotiated Rate |
$196.50 |
| Rate for Payer: Blue Shield of California Commercial |
$164.60
|
| Rate for Payer: Blue Shield of California EPN |
$118.36
|
| Rate for Payer: Cash Price |
$104.03
|
| Rate for Payer: Cigna of CA HMO |
$161.83
|
| Rate for Payer: Cigna of CA PPO |
$161.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.47
|
| Rate for Payer: Galaxy Health WC |
$196.50
|
| Rate for Payer: Global Benefits Group Commercial |
$138.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$154.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.48
|
| Rate for Payer: Multiplan Commercial |
$184.94
|
| Rate for Payer: Networks By Design Commercial |
$150.27
|
| Rate for Payer: Prime Health Services Commercial |
$196.50
|
|
|
CAPMATINIB 200 MG TABLET [228061]
|
Facility
|
OP
|
$231.18
|
|
|
Service Code
|
NDC 0078-0716-56
|
| Hospital Charge Code |
ERX228061
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.48 |
| Max. Negotiated Rate |
$196.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$151.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$196.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$127.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$127.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$137.74
|
| Rate for Payer: Blue Distinction Transplant |
$138.71
|
| Rate for Payer: Blue Shield of California Commercial |
$170.38
|
| Rate for Payer: Blue Shield of California EPN |
$135.01
|
| Rate for Payer: Cash Price |
$104.03
|
| Rate for Payer: Cigna of CA HMO |
$161.83
|
| Rate for Payer: Cigna of CA PPO |
$161.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$196.50
|
| Rate for Payer: Dignity Health Media |
$196.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$196.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$92.47
|
| Rate for Payer: Galaxy Health WC |
$196.50
|
| Rate for Payer: Global Benefits Group Commercial |
$138.71
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$173.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$154.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.48
|
| Rate for Payer: Multiplan Commercial |
$184.94
|
| Rate for Payer: Networks By Design Commercial |
$150.27
|
| Rate for Payer: Prime Health Services Commercial |
$196.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$138.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$138.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$115.59
|
| Rate for Payer: United Healthcare All Other HMO |
$115.59
|
| Rate for Payer: United Healthcare HMO Rider |
$115.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$115.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$196.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$196.50
|
| Rate for Payer: Vantage Medical Group Senior |
$196.50
|
|
|
CAPMATINIB 200 MG TABLET [228061]
|
Facility
|
IP
|
$231.18
|
|
|
Service Code
|
NDC 0078-0716-56
|
| Hospital Charge Code |
ERX228061
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.48 |
| Max. Negotiated Rate |
$196.50 |
| Rate for Payer: Blue Shield of California Commercial |
$164.60
|
| Rate for Payer: Blue Shield of California EPN |
$118.36
|
| Rate for Payer: Cash Price |
$104.03
|
| Rate for Payer: Cigna of CA HMO |
$161.83
|
| Rate for Payer: Cigna of CA PPO |
$161.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.47
|
| Rate for Payer: Galaxy Health WC |
$196.50
|
| Rate for Payer: Global Benefits Group Commercial |
$138.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$154.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.48
|
| Rate for Payer: Multiplan Commercial |
$184.94
|
| Rate for Payer: Networks By Design Commercial |
$150.27
|
| Rate for Payer: Prime Health Services Commercial |
$196.50
|
|
|
CAPSAICIN 0.025 % TOPICAL CREAM [1350]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0536-2525-25
|
| Hospital Charge Code |
1743536
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
CAPSAICIN 0.025 % TOPICAL CREAM [1350]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0536-2525-25
|
| Hospital Charge Code |
1743536
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
CAPSAICIN 0.075 % TOPICAL CREAM [9399]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0536-1118-25
|
| Hospital Charge Code |
NDG9399A
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Distinction 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) 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: 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
|
|
|
CAPSAICIN 0.075 % TOPICAL CREAM [9399]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0536-1118-25
|
| Hospital Charge Code |
NDG9399A
|
|
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
|
|
|
Capsulectomy or capsulotomy; interphalangeal joint, each joint
|
Facility
|
OP
|
$9,590.00
|
|
|
Service Code
|
CPT 26525
|
| Min. Negotiated Rate |
$660.69 |
| Max. Negotiated Rate |
$9,590.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9,590.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,208.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,008.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,282.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Dignity Health Media |
$2,008.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,208.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,710.92
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,008.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,008.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,293.27
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,293.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,253.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3,253.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,008.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$660.69
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,008.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,530.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,690.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,208.90
|
| Rate for Payer: Vantage Medical Group Senior |
$2,008.09
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
IP
|
$1.22
|
|
|
Service Code
|
NDC 0143-1171-01
|
| Hospital Charge Code |
1711381
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.79
|
| Rate for Payer: Prime Health Services Commercial |
$1.04
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 69292-522-01
|
| Hospital Charge Code |
1711381
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.71
|
| Rate for Payer: Blue Distinction Transplant |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Media |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 69292-522-01
|
| Hospital Charge Code |
1711381
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
IP
|
$1.70
|
|
|
Service Code
|
NDC 60687-304-11
|
| Hospital Charge Code |
1711381
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO |
$1.19
|
| Rate for Payer: Cigna of CA PPO |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Galaxy Health WC |
$1.44
|
| Rate for Payer: Global Benefits Group Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.36
|
| Rate for Payer: Networks By Design Commercial |
$1.10
|
| Rate for Payer: Prime Health Services Commercial |
$1.44
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
NDC 60687-304-21
|
| Hospital Charge Code |
1711381
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Blue Distinction Transplant |
$1.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO |
$1.19
|
| Rate for Payer: Cigna of CA PPO |
$1.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.44
|
| Rate for Payer: Dignity Health Media |
$1.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.68
|
| Rate for Payer: Galaxy Health WC |
$1.44
|
| Rate for Payer: Global Benefits Group Commercial |
$1.02
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.36
|
| Rate for Payer: Networks By Design Commercial |
$1.10
|
| Rate for Payer: Prime Health Services Commercial |
$1.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.85
|
| Rate for Payer: United Healthcare All Other HMO |
$0.85
|
| Rate for Payer: United Healthcare HMO Rider |
$0.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.44
|
| Rate for Payer: Vantage Medical Group Senior |
$1.44
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
IP
|
$1.70
|
|
|
Service Code
|
NDC 60687-304-21
|
| Hospital Charge Code |
1711381
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO |
$1.19
|
| Rate for Payer: Cigna of CA PPO |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Galaxy Health WC |
$1.44
|
| Rate for Payer: Global Benefits Group Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.36
|
| Rate for Payer: Networks By Design Commercial |
$1.10
|
| Rate for Payer: Prime Health Services Commercial |
$1.44
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
NDC 0143-1171-01
|
| Hospital Charge Code |
1711381
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.73
|
| Rate for Payer: Blue Distinction Transplant |
$0.73
|
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.71
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.04
|
| Rate for Payer: Dignity Health Media |
$1.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.79
|
| Rate for Payer: Prime Health Services Commercial |
$1.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.61
|
| Rate for Payer: United Healthcare All Other HMO |
$0.61
|
| Rate for Payer: United Healthcare HMO Rider |
$0.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Vantage Medical Group Senior |
$1.04
|
|
|
CAPTOPRIL 12.5 MG TABLET [9401]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
NDC 60687-304-11
|
| Hospital Charge Code |
1711381
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Blue Distinction Transplant |
$1.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO |
$1.19
|
| Rate for Payer: Cigna of CA PPO |
$1.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.44
|
| Rate for Payer: Dignity Health Media |
$1.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.68
|
| Rate for Payer: Galaxy Health WC |
$1.44
|
| Rate for Payer: Global Benefits Group Commercial |
$1.02
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.36
|
| Rate for Payer: Networks By Design Commercial |
$1.10
|
| Rate for Payer: Prime Health Services Commercial |
$1.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.85
|
| Rate for Payer: United Healthcare All Other HMO |
$0.85
|
| Rate for Payer: United Healthcare HMO Rider |
$0.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.44
|
| Rate for Payer: Vantage Medical Group Senior |
$1.44
|
|
|
CAPTOPRIL 25 MG TABLET [9402]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 60687-315-21
|
| Hospital Charge Code |
1712016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.10
|
| Rate for Payer: Blue Distinction Transplant |
$1.11
|
| Rate for Payer: Blue Shield of California Commercial |
$1.36
|
| Rate for Payer: Blue Shield of California EPN |
$1.08
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna of CA HMO |
$1.30
|
| Rate for Payer: Cigna of CA PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.57
|
| Rate for Payer: Dignity Health Media |
$1.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.74
|
| Rate for Payer: Galaxy Health WC |
$1.57
|
| Rate for Payer: Global Benefits Group Commercial |
$1.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$1.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.93
|
| Rate for Payer: United Healthcare All Other HMO |
$0.93
|
| Rate for Payer: United Healthcare HMO Rider |
$0.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.57
|
| Rate for Payer: Vantage Medical Group Senior |
$1.57
|
|
|
CAPTOPRIL 25 MG TABLET [9402]
|
Facility
|
IP
|
$1.27
|
|
|
Service Code
|
NDC 69292-524-01
|
| Hospital Charge Code |
1712016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO |
$0.89
|
| Rate for Payer: Cigna of CA PPO |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Galaxy Health WC |
$1.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: Networks By Design Commercial |
$0.83
|
| Rate for Payer: Prime Health Services Commercial |
$1.08
|
|
|
CAPTOPRIL 25 MG TABLET [9402]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 60687-315-11
|
| Hospital Charge Code |
1712016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.10
|
| Rate for Payer: Blue Distinction Transplant |
$1.11
|
| Rate for Payer: Blue Shield of California Commercial |
$1.36
|
| Rate for Payer: Blue Shield of California EPN |
$1.08
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna of CA HMO |
$1.30
|
| Rate for Payer: Cigna of CA PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.57
|
| Rate for Payer: Dignity Health Media |
$1.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.74
|
| Rate for Payer: Galaxy Health WC |
$1.57
|
| Rate for Payer: Global Benefits Group Commercial |
$1.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$1.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.93
|
| Rate for Payer: United Healthcare All Other HMO |
$0.93
|
| Rate for Payer: United Healthcare HMO Rider |
$0.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.57
|
| Rate for Payer: Vantage Medical Group Senior |
$1.57
|
|
|
CAPTOPRIL 25 MG TABLET [9402]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 0781-8061-01
|
| Hospital Charge Code |
1712016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.71
|
| Rate for Payer: Cigna of CA PPO |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Galaxy Health WC |
$0.87
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: Networks By Design Commercial |
$0.66
|
| Rate for Payer: Prime Health Services Commercial |
$0.87
|
|
