|
LAMOTRIGINE 200 MG TABLET [13983]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 29300-114-16
|
| Hospital Charge Code |
1711641
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.15
|
| 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 |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
LAMOTRIGINE 200 MG TABLET [13983]
|
Facility
OP
|
$0.25
|
|
|
Service Code
|
NDC 51079-866-01
|
| Hospital Charge Code |
1711641
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| 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 |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: BCBS Transplant Transplant |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| 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: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.19
|
| 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 |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: Riverside University Health MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.15
|
| 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 |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
LAMOTRIGINE 200 MG TABLET [13983]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
NDC 29300-114-16
|
| Hospital Charge Code |
1711641
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| 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 |
$0.10
|
| Rate for Payer: BCBS Transplant Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.13
|
| 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 |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: Riverside University Health MISP |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
LAMOTRIGINE 25 MG CHEWABLE DISPERSIBLE TABLET [103880]
|
Facility
OP
|
$0.53
|
|
|
Service Code
|
NDC 68462-229-01
|
| Hospital Charge Code |
1711994
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: BCBS Transplant Transplant |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Central Health Plan Commercial |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.40
|
| Rate for Payer: IEHP medi-cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: Riverside University Health MISP |
$0.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO |
$0.27
|
| Rate for Payer: United Healthcare HMO Rider |
$0.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
LAMOTRIGINE 25 MG CHEWABLE DISPERSIBLE TABLET [103880]
|
Facility
IP
|
$0.53
|
|
|
Service Code
|
NDC 62332-096-31
|
| Hospital Charge Code |
1711994
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Central Health Plan Commercial |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
|
|
LAMOTRIGINE 25 MG CHEWABLE DISPERSIBLE TABLET [103880]
|
Facility
IP
|
$0.53
|
|
|
Service Code
|
NDC 68462-229-01
|
| Hospital Charge Code |
1711994
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Central Health Plan Commercial |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
|
|
LAMOTRIGINE 25 MG CHEWABLE DISPERSIBLE TABLET [103880]
|
Facility
OP
|
$0.53
|
|
|
Service Code
|
NDC 62332-096-31
|
| Hospital Charge Code |
1711994
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: BCBS Transplant Transplant |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Central Health Plan Commercial |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.40
|
| Rate for Payer: IEHP medi-cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: Riverside University Health MISP |
$0.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO |
$0.27
|
| Rate for Payer: United Healthcare HMO Rider |
$0.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
LAMOTRIGINE 25 MG DISINTEGRATING TABLET [97830]
|
Facility
IP
|
$16.07
|
|
|
Service Code
|
NDC 0173-0772-02
|
| Hospital Charge Code |
1712434
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$14.46 |
| Rate for Payer: Blue Shield of California Commercial |
$12.05
|
| Rate for Payer: Blue Shield of California EPN |
$8.58
|
| Rate for Payer: Cash Price |
$7.23
|
| Rate for Payer: Central Health Plan Commercial |
$12.86
|
| Rate for Payer: Cigna of CA HMO |
$11.25
|
| Rate for Payer: Cigna of CA PPO |
$11.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.43
|
| Rate for Payer: Galaxy Health WC |
$13.66
|
| Rate for Payer: Global Benefits Group Commercial |
$9.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$12.05
|
| Rate for Payer: Networks By Design Commercial |
$10.45
|
| Rate for Payer: Prime Health Services Commercial |
$13.66
|
|
|
LAMOTRIGINE 25 MG DISINTEGRATING TABLET [97830]
|
Facility
OP
|
$16.07
|
|
|
Service Code
|
NDC 0173-0772-02
|
| Hospital Charge Code |
1712434
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$14.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.84
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.49
|
| Rate for Payer: BCBS Transplant Transplant |
$9.64
|
| Rate for Payer: Blue Shield of California Commercial |
$10.11
|
| Rate for Payer: Blue Shield of California EPN |
$7.86
|
| Rate for Payer: Cash Price |
$7.23
|
| Rate for Payer: Central Health Plan Commercial |
$12.86
|
| Rate for Payer: Cigna of CA HMO |
$11.25
|
| Rate for Payer: Cigna of CA PPO |
$11.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.43
|
| Rate for Payer: Galaxy Health WC |
$13.66
|
| Rate for Payer: Global Benefits Group Commercial |
$9.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.46
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$12.05
|
| Rate for Payer: IEHP medi-cal |
$5.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: Multiplan Commercial |
$12.05
|
| Rate for Payer: Networks By Design Commercial |
$10.45
|
| Rate for Payer: Prime Health Services Commercial |
$13.66
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$9.64
|
| Rate for Payer: Riverside University Health MISP |
$6.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.04
|
| Rate for Payer: United Healthcare All Other HMO |
$8.04
|
| Rate for Payer: United Healthcare HMO Rider |
$8.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.66
|
| Rate for Payer: Vantage Medical Group Senior |
$13.66
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
NDC 29300-111-01
|
| Hospital Charge Code |
1711638
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| 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: Central Health Plan Commercial |
$0.06
|
| 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: Health Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
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 |
$0.01 |
| 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: Central Health Plan Commercial |
$0.06
|
| 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: Health Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| 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 29300-111-01
|
| Hospital Charge Code |
1711638
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| 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 Exchange |
$0.03
|
| 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 |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| 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: 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 Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.05
|
| Rate for Payer: IEHP medi-cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| 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: Riverside University Health MISP |
$0.03
|
| 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 Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| 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 Exchange |
$0.03
|
| 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 |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| 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: 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 Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.05
|
| Rate for Payer: IEHP medi-cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| 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: Riverside University Health MISP |
$0.03
|
| 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 Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
OP
|
$0.22
|
|
|
Service Code
|
NDC 68084-318-11
|
| Hospital Charge Code |
1711638
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.17
|
| Rate for Payer: IEHP medi-cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: Riverside University Health MISP |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| 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: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 51672-4130-1
|
| Hospital Charge Code |
1711638
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| 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 Exchange |
$0.03
|
| 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 |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| 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: 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 Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.05
|
| Rate for Payer: IEHP medi-cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| 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: Riverside University Health MISP |
$0.03
|
| 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 Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
NDC 13668-045-01
|
| Hospital Charge Code |
1711638
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| 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: Central Health Plan Commercial |
$0.06
|
| 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: Health Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
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 |
$1.83 |
| Max. Negotiated Rate |
$8.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.54
|
| 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 Exchange |
$4.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.39
|
| Rate for Payer: BCBS Transplant Transplant |
$5.48
|
| Rate for Payer: Blue Shield of California Commercial |
$5.74
|
| Rate for Payer: Blue Shield of California EPN |
$4.46
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Central Health Plan Commercial |
$7.30
|
| 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: 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 Management Network EPO/PPO |
$8.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.85
|
| Rate for Payer: IEHP medi-cal |
$3.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
| 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: Riverside University Health MISP |
$3.65
|
| 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 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 |
$1.83 |
| Max. Negotiated Rate |
$8.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.54
|
| 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 Exchange |
$4.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.39
|
| Rate for Payer: BCBS Transplant Transplant |
$5.48
|
| Rate for Payer: Blue Shield of California Commercial |
$5.74
|
| Rate for Payer: Blue Shield of California EPN |
$4.46
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Central Health Plan Commercial |
$7.30
|
| 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: 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 Management Network EPO/PPO |
$8.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.85
|
| Rate for Payer: IEHP medi-cal |
$3.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
| 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: Riverside University Health MISP |
$3.65
|
| 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 Medi-Cal |
$7.76
|
| Rate for Payer: Vantage Medical Group Senior |
$7.76
|
|
|
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 |
$1.83 |
| Max. Negotiated Rate |
$8.22 |
| Rate for Payer: Blue Shield of California Commercial |
$6.85
|
| Rate for Payer: Blue Shield of California EPN |
$4.88
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Central Health Plan Commercial |
$7.30
|
| 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: Health Management Network EPO/PPO |
$8.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
| 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 |
$1.83 |
| Max. Negotiated Rate |
$8.22 |
| Rate for Payer: Blue Shield of California Commercial |
$6.85
|
| Rate for Payer: Blue Shield of California EPN |
$4.88
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Central Health Plan Commercial |
$7.30
|
| 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: Health Management Network EPO/PPO |
$8.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
| 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 49884-485-11
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$8.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.54
|
| 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 Exchange |
$4.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.39
|
| Rate for Payer: BCBS Transplant Transplant |
$5.48
|
| Rate for Payer: Blue Shield of California Commercial |
$5.74
|
| Rate for Payer: Blue Shield of California EPN |
$4.46
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Central Health Plan Commercial |
$7.30
|
| 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: 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 Management Network EPO/PPO |
$8.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.85
|
| Rate for Payer: IEHP medi-cal |
$3.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
| 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: Riverside University Health MISP |
$3.65
|
| 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 Medi-Cal |
$7.76
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$1.83 |
| Max. Negotiated Rate |
$8.22 |
| Rate for Payer: Blue Shield of California Commercial |
$6.85
|
| Rate for Payer: Blue Shield of California EPN |
$4.88
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Central Health Plan Commercial |
$7.30
|
| 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: Health Management Network EPO/PPO |
$8.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
| 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
|
$6.36
|
|
|
Service Code
|
NDC 27241-184-30
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.72 |
| Rate for Payer: Blue Shield of California Commercial |
$4.77
|
| Rate for Payer: Blue Shield of California EPN |
$3.40
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Central Health Plan Commercial |
$5.09
|
| 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: Health Management Network EPO/PPO |
$5.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: Multiplan Commercial |
$4.77
|
| 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
|
$6.36
|
|
|
Service Code
|
NDC 27241-184-30
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.86
|
| 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 Exchange |
$3.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.76
|
| Rate for Payer: BCBS Transplant Transplant |
$3.82
|
| Rate for Payer: Blue Shield of California Commercial |
$4.00
|
| Rate for Payer: Blue Shield of California EPN |
$3.11
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Central Health Plan Commercial |
$5.09
|
| 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: 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 Management Network EPO/PPO |
$5.72
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.77
|
| Rate for Payer: IEHP medi-cal |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: Multiplan Commercial |
$4.77
|
| 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: Riverside University Health MISP |
$2.54
|
| 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 Medi-Cal |
$5.41
|
| Rate for Payer: Vantage Medical Group Senior |
$5.41
|
|
