|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
IP
|
$0.25
|
|
|
Service Code
|
NDC 62175-128-37
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
NDC 50742-175-01
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| 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: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| 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
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
IP
|
$0.83
|
|
|
Service Code
|
NDC 50268-451-15
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Central Health Plan Commercial |
$0.66
|
| Rate for Payer: Cigna of CA HMO |
$0.58
|
| Rate for Payer: Cigna of CA PPO |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.54
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
OP
|
$0.63
|
|
|
Service Code
|
NDC 68084-591-11
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: BCBS Transplant Transplant |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.44
|
| Rate for Payer: Cigna of CA PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.57
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.47
|
| Rate for Payer: IEHP medi-cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.41
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: Riverside University Health MISP |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.32
|
| Rate for Payer: United Healthcare HMO Rider |
$0.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
OP
|
$0.83
|
|
|
Service Code
|
NDC 50268-451-15
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.49
|
| Rate for Payer: BCBS Transplant Transplant |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Central Health Plan Commercial |
$0.66
|
| Rate for Payer: Cigna of CA HMO |
$0.58
|
| Rate for Payer: Cigna of CA PPO |
$0.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.75
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.62
|
| Rate for Payer: IEHP medi-cal |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.54
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: Riverside University Health MISP |
$0.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
OP
|
$0.84
|
|
|
Service Code
|
NDC 68084-592-11
|
| Hospital Charge Code |
1711622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: BCBS Transplant Transplant |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Central Health Plan Commercial |
$0.67
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.76
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.63
|
| Rate for Payer: IEHP medi-cal |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: Riverside University Health MISP |
$0.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
IP
|
$0.26
|
|
|
Service Code
|
NDC 62175-119-37
|
| Hospital Charge Code |
1711622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
IP
|
$0.16
|
|
|
Service Code
|
NDC 50742-176-01
|
| Hospital Charge Code |
1711622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
OP
|
$0.26
|
|
|
Service Code
|
NDC 62175-119-37
|
| Hospital Charge Code |
1711622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: BCBS Transplant Transplant |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.20
|
| Rate for Payer: IEHP medi-cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: Riverside University Health MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
IP
|
$0.84
|
|
|
Service Code
|
NDC 68084-592-11
|
| Hospital Charge Code |
1711622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Central Health Plan Commercial |
$0.67
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
OP
|
$0.16
|
|
|
Service Code
|
NDC 50742-176-01
|
| Hospital Charge Code |
1711622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: BCBS Transplant Transplant |
$0.10
|
| 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 |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.14
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.12
|
| Rate for Payer: IEHP medi-cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: Riverside University Health MISP |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION [10358]
|
Facility
OP
|
$254.61
|
|
|
Service Code
|
CPT Q9968
|
| Hospital Charge Code |
1721183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$229.15 |
| Rate for Payer: Adventist Health Medi-Cal |
$7.95
|
| Rate for Payer: Adventist Health Medi-Cal |
$7.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$107.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$107.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.74
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.56
|
| Rate for Payer: BCBS Transplant Transplant |
$152.77
|
| Rate for Payer: BCBS Transplant Transplant |
$90.58
|
| Rate for Payer: Blue Shield of California Commercial |
$94.95
|
| Rate for Payer: Blue Shield of California Commercial |
$160.15
|
| Rate for Payer: Blue Shield of California EPN |
$73.82
|
| Rate for Payer: Blue Shield of California EPN |
$124.50
|
| Rate for Payer: Caremore Medicare Advantage |
$7.95
|
| Rate for Payer: Caremore Medicare Advantage |
$7.95
|
| Rate for Payer: Cash Price |
$114.57
|
| Rate for Payer: Cash Price |
$67.93
|
| Rate for Payer: Cash Price |
$114.57
|
| Rate for Payer: Cash Price |
$67.93
|
| Rate for Payer: Central Health Plan Commercial |
$203.69
|
| Rate for Payer: Central Health Plan Commercial |
$120.77
|
| Rate for Payer: Cigna of CA HMO |
$178.23
|
| Rate for Payer: Cigna of CA HMO |
$105.67
|
| Rate for Payer: Cigna of CA PPO |
$178.23
|
| Rate for Payer: Cigna of CA PPO |
$105.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.73
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7.95
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.95
|
| Rate for Payer: Galaxy Health WC |
$128.32
|
| Rate for Payer: Galaxy Health WC |
$216.42
|
| Rate for Payer: Global Benefits Group Commercial |
$152.77
|
| Rate for Payer: Global Benefits Group Commercial |
$90.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$135.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$229.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$190.96
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$113.22
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$13.04
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$13.04
|
| Rate for Payer: IEHP medi-cal |
$13.12
|
| Rate for Payer: IEHP medi-cal |
$13.12
|
| Rate for Payer: IEHP Medicare Advantage |
$7.95
|
| Rate for Payer: IEHP Medicare Advantage |
$7.95
|
| Rate for Payer: Innovage PACE Commercial |
$11.92
|
| Rate for Payer: Innovage PACE Commercial |
$11.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$169.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$100.69
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.65
|
| Rate for Payer: Multiplan Commercial |
$113.22
|
| Rate for Payer: Multiplan Commercial |
$190.96
|
| Rate for Payer: Networks By Design Commercial |
$127.30
|
| Rate for Payer: Networks By Design Commercial |
$75.48
|
| Rate for Payer: Prime Health Services Commercial |
$216.42
|
| Rate for Payer: Prime Health Services Commercial |
$128.32
|
| Rate for Payer: Prime Health Services Medicare |
$8.43
|
| Rate for Payer: Prime Health Services Medicare |
$8.43
|
| Rate for Payer: Riverside University Health MISP |
$8.74
|
| Rate for Payer: Riverside University Health MISP |
$8.74
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$152.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$90.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$90.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$152.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$127.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$75.48
|
| Rate for Payer: United Healthcare All Other HMO |
$127.30
|
| Rate for Payer: United Healthcare All Other HMO |
$75.48
|
| Rate for Payer: United Healthcare HMO Rider |
$75.48
|
| Rate for Payer: United Healthcare HMO Rider |
$127.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$127.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$75.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.74
|
| Rate for Payer: Vantage Medical Group Senior |
$7.95
|
| Rate for Payer: Vantage Medical Group Senior |
$7.95
|
|
|
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION [10358]
|
Facility
IP
|
$150.96
|
|
|
Service Code
|
CPT Q9968
|
| Hospital Charge Code |
1721183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.19 |
| Max. Negotiated Rate |
$135.86 |
| Rate for Payer: Blue Shield of California Commercial |
$113.22
|
| Rate for Payer: Blue Shield of California Commercial |
$190.96
|
| Rate for Payer: Blue Shield of California EPN |
$135.96
|
| Rate for Payer: Blue Shield of California EPN |
$80.61
|
| Rate for Payer: Cash Price |
$67.93
|
| Rate for Payer: Cash Price |
$114.57
|
| Rate for Payer: Central Health Plan Commercial |
$203.69
|
| Rate for Payer: Central Health Plan Commercial |
$120.77
|
| Rate for Payer: Cigna of CA HMO |
$105.67
|
| Rate for Payer: Cigna of CA HMO |
$178.23
|
| Rate for Payer: Cigna of CA PPO |
$178.23
|
| Rate for Payer: Cigna of CA PPO |
$105.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$101.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$60.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$101.84
|
| Rate for Payer: Galaxy Health WC |
$128.32
|
| Rate for Payer: Galaxy Health WC |
$216.42
|
| Rate for Payer: Global Benefits Group Commercial |
$90.58
|
| Rate for Payer: Global Benefits Group Commercial |
$152.77
|
| Rate for Payer: Health Management Network EPO/PPO |
$135.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$229.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$169.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$100.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.19
|
| Rate for Payer: Multiplan Commercial |
$190.96
|
| Rate for Payer: Multiplan Commercial |
$113.22
|
| Rate for Payer: Networks By Design Commercial |
$127.30
|
| Rate for Payer: Networks By Design Commercial |
$75.48
|
| Rate for Payer: Prime Health Services Commercial |
$128.32
|
| Rate for Payer: Prime Health Services Commercial |
$216.42
|
|
|
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 |
$1.20 |
| Max. Negotiated Rate |
$5.42 |
| Rate for Payer: Blue Shield of California Commercial |
$4.52
|
| Rate for Payer: Blue Shield of California EPN |
$3.21
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Central Health Plan Commercial |
$4.82
|
| 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: Health Management Network EPO/PPO |
$5.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
| 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 |
$1.72 |
| Max. Negotiated Rate |
$7.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.21
|
| 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 Exchange |
$4.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.07
|
| Rate for Payer: BCBS Transplant Transplant |
$5.15
|
| Rate for Payer: Blue Shield of California Commercial |
$5.40
|
| Rate for Payer: Blue Shield of California EPN |
$4.20
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Central Health Plan Commercial |
$6.86
|
| 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: 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 Management Network EPO/PPO |
$7.72
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.44
|
| Rate for Payer: IEHP medi-cal |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$6.44
|
| 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: Riverside University Health MISP |
$3.43
|
| 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 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 |
$1.72 |
| Max. Negotiated Rate |
$7.72 |
| Rate for Payer: Blue Shield of California Commercial |
$6.44
|
| Rate for Payer: Blue Shield of California EPN |
$4.58
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Central Health Plan Commercial |
$6.86
|
| 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: Health Management Network EPO/PPO |
$7.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$6.44
|
| Rate for Payer: Networks By Design Commercial |
$5.58
|
| Rate for Payer: Prime Health Services Commercial |
$7.29
|
|
|
ISOTRETINOIN 10 MG CAPSULE [10359]
|
Facility
OP
|
$6.02
|
|
|
Service Code
|
NDC 0378-6611-93
|
| Hospital Charge Code |
1710001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.56
|
| Rate for Payer: BCBS Transplant Transplant |
$3.61
|
| Rate for Payer: Blue Shield of California Commercial |
$3.79
|
| Rate for Payer: Blue Shield of California EPN |
$2.94
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Central Health Plan Commercial |
$4.82
|
| Rate for Payer: Cigna of CA HMO |
$4.21
|
| Rate for Payer: Cigna of CA PPO |
$4.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.12
|
| Rate for Payer: Global Benefits Group Commercial |
$3.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.42
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.52
|
| Rate for Payer: IEHP medi-cal |
$2.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
| Rate for Payer: Networks By Design Commercial |
$3.91
|
| Rate for Payer: Prime Health Services Commercial |
$5.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.61
|
| Rate for Payer: Riverside University Health MISP |
$2.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.01
|
| Rate for Payer: United Healthcare All Other HMO |
$3.01
|
| Rate for Payer: United Healthcare HMO Rider |
$3.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.12
|
| Rate for Payer: Vantage Medical Group Senior |
$5.12
|
|
|
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 |
$3.37 |
| Max. Negotiated Rate |
$15.15 |
| Rate for Payer: Blue Shield of California Commercial |
$12.62
|
| Rate for Payer: Blue Shield of California EPN |
$8.99
|
| Rate for Payer: Cash Price |
$7.57
|
| Rate for Payer: Central Health Plan Commercial |
$13.46
|
| 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: Health Management Network EPO/PPO |
$15.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.37
|
| Rate for Payer: Multiplan Commercial |
$12.62
|
| Rate for Payer: Networks By Design Commercial |
$10.94
|
| Rate for Payer: Prime Health Services Commercial |
$14.31
|
|
|
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 |
$1.43 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.34
|
| 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 Exchange |
$3.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.22
|
| Rate for Payer: BCBS Transplant Transplant |
$4.28
|
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$3.49
|
| Rate for Payer: Cash Price |
$3.21
|
| Rate for Payer: Central Health Plan Commercial |
$5.71
|
| 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: 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 Management Network EPO/PPO |
$6.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.36
|
| Rate for Payer: IEHP medi-cal |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| 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: Riverside University Health MISP |
$2.86
|
| 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 Medi-Cal |
$6.07
|
| Rate for Payer: Vantage Medical Group Senior |
$6.07
|
|
|
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 |
$1.43 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Blue Shield of California Commercial |
$5.36
|
| Rate for Payer: Blue Shield of California EPN |
$3.81
|
| Rate for Payer: Cash Price |
$3.21
|
| Rate for Payer: Central Health Plan Commercial |
$5.71
|
| 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: Health Management Network EPO/PPO |
$6.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| 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 |
$3.37 |
| Max. Negotiated Rate |
$15.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$10.22
|
| 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 Exchange |
$8.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.94
|
| Rate for Payer: BCBS Transplant Transplant |
$10.10
|
| Rate for Payer: Blue Shield of California Commercial |
$10.59
|
| Rate for Payer: Blue Shield of California EPN |
$8.23
|
| Rate for Payer: Cash Price |
$7.57
|
| Rate for Payer: Central Health Plan Commercial |
$13.46
|
| 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: 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 Management Network EPO/PPO |
$15.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$12.62
|
| Rate for Payer: IEHP medi-cal |
$5.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.37
|
| Rate for Payer: Multiplan Commercial |
$12.62
|
| 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: Riverside University Health MISP |
$6.73
|
| 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 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 |
$1.99 |
| Max. Negotiated Rate |
$8.95 |
| Rate for Payer: Blue Shield of California Commercial |
$7.46
|
| Rate for Payer: Blue Shield of California EPN |
$5.31
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Central Health Plan Commercial |
$7.95
|
| 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: Health Management Network EPO/PPO |
$8.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.99
|
| Rate for Payer: Multiplan Commercial |
$7.46
|
| Rate for Payer: Networks By Design Commercial |
$6.46
|
| Rate for Payer: Prime Health Services Commercial |
$8.45
|
|
|
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 |
$1.99 |
| Max. Negotiated Rate |
$8.95 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.04
|
| 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 Exchange |
$4.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.87
|
| Rate for Payer: BCBS Transplant Transplant |
$5.96
|
| Rate for Payer: Blue Shield of California Commercial |
$6.25
|
| Rate for Payer: Blue Shield of California EPN |
$4.86
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Central Health Plan Commercial |
$7.95
|
| 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: 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 Management Network EPO/PPO |
$8.95
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$7.46
|
| Rate for Payer: IEHP medi-cal |
$3.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.99
|
| Rate for Payer: Multiplan Commercial |
$7.46
|
| 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: Riverside University Health MISP |
$3.98
|
| 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 Medi-Cal |
$8.45
|
| Rate for Payer: Vantage Medical Group Senior |
$8.45
|
|
|
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 |
$2.37 |
| Max. Negotiated Rate |
$10.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.19
|
| 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 Exchange |
$5.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.00
|
| Rate for Payer: BCBS Transplant Transplant |
$7.10
|
| Rate for Payer: Blue Shield of California Commercial |
$7.45
|
| Rate for Payer: Blue Shield of California EPN |
$5.79
|
| Rate for Payer: Cash Price |
$5.33
|
| Rate for Payer: Central Health Plan Commercial |
$9.47
|
| 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: 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 Management Network EPO/PPO |
$10.66
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.88
|
| Rate for Payer: IEHP medi-cal |
$4.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$8.88
|
| 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: Riverside University Health MISP |
$4.74
|
| 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 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 |
$1.66 |
| Max. Negotiated Rate |
$7.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.04
|
| 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 Exchange |
$4.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.90
|
| Rate for Payer: BCBS Transplant Transplant |
$4.98
|
| Rate for Payer: Blue Shield of California Commercial |
$5.22
|
| Rate for Payer: Blue Shield of California EPN |
$4.06
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Central Health Plan Commercial |
$6.64
|
| 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: 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 Management Network EPO/PPO |
$7.47
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.22
|
| Rate for Payer: IEHP medi-cal |
$2.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.66
|
| Rate for Payer: Multiplan Commercial |
$6.22
|
| 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: Riverside University Health MISP |
$3.32
|
| 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 Medi-Cal |
$7.06
|
| Rate for Payer: Vantage Medical Group Senior |
$7.06
|
|
