|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 6068790011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Riverside University Health System MISP |
$0.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 6068790001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Riverside University Health System MISP |
$0.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 5167240011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 0093081001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| 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: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.16
|
| Rate for Payer: Cigna of CA PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.15
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Riverside University Health System MISP |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 6068790001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 6068790011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 7590706901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Riverside University Health System MISP |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 5167240015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 7590706901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
NORTRIPTYLINE 10 MG CAPSULE [5674]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 5167240015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
| Rate for Payer: Riverside University Health System MISP |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 7590707001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 5026860415
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.47
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.50
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.50
|
| Rate for Payer: Riverside University Health System MISP |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Vantage Medical Group Senior |
$0.50
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 0093081101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
| Rate for Payer: Riverside University Health System MISP |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO |
$0.16
|
| Rate for Payer: United Healthcare HMO Rider |
$0.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 7590707001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 5167240021
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
| Rate for Payer: Riverside University Health System MISP |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO |
$0.16
|
| Rate for Payer: United Healthcare HMO Rider |
$0.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 5167240021
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 5026860411
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.47
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.50
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.50
|
| Rate for Payer: Riverside University Health System MISP |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Vantage Medical Group Senior |
$0.50
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 5026860415
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.47
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.50
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.50
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 5026860411
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.47
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.50
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.50
|
|
|
NORTRIPTYLINE 25 MG CAPSULE [5675]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 0093081101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
|
|
NUSINERSEN (PF) 12 MG/5 ML INTRATHECAL SOLUTION [216584]
|
Facility
|
IP
|
$36,428.44
|
|
|
Service Code
|
HCPCS J2326
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,285.69 |
| Max. Negotiated Rate |
$32,785.60 |
| Rate for Payer: Adventist Health Commercial |
$7,285.69
|
| Rate for Payer: Blue Shield of California Commercial |
$29,215.61
|
| Rate for Payer: Blue Shield of California EPN |
$18,359.93
|
| Rate for Payer: Cash Price |
$16,392.80
|
| Rate for Payer: Central Health Plan Commercial |
$29,142.75
|
| Rate for Payer: Cigna of CA HMO |
$25,499.91
|
| Rate for Payer: Cigna of CA PPO |
$25,499.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25,499.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$14,571.38
|
| Rate for Payer: EPIC Health Plan Senior |
$14,571.38
|
| Rate for Payer: Galaxy Health WC |
$30,964.17
|
| Rate for Payer: Global Benefits Group Commercial |
$21,857.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$32,785.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23,132.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21,492.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,285.69
|
| Rate for Payer: Multiplan Commercial |
$27,321.33
|
| Rate for Payer: Networks By Design Commercial |
$18,214.22
|
| Rate for Payer: Prime Health Services Commercial |
$30,964.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,671.59
|
| Rate for Payer: United Healthcare All Other HMO |
$13,307.31
|
| Rate for Payer: United Healthcare HMO Rider |
$13,019.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,930.31
|
|
|
NUSINERSEN (PF) 12 MG/5 ML INTRATHECAL SOLUTION [216584]
|
Facility
|
OP
|
$36,428.44
|
|
|
Service Code
|
HCPCS J2326
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,333.45 |
| Max. Negotiated Rate |
$32,785.60 |
| Rate for Payer: Adventist Health Commercial |
$7,285.69
|
| Rate for Payer: Adventist Health Medi-Cal |
$1,333.45
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7,233.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,466.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,466.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2,061.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,572.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1,562.42
|
| Rate for Payer: Blue Shield of California EPN |
$1,420.38
|
| Rate for Payer: Cash Price |
$16,392.80
|
| Rate for Payer: Cash Price |
$16,392.80
|
| Rate for Payer: Central Health Plan Commercial |
$29,142.75
|
| Rate for Payer: Cigna of CA HMO |
$25,499.91
|
| Rate for Payer: Cigna of CA PPO |
$25,499.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,466.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,466.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25,499.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,200.19
|
| Rate for Payer: EPIC Health Plan Senior |
$1,466.80
|
| Rate for Payer: Galaxy Health WC |
$30,964.17
|
| Rate for Payer: Global Benefits Group Commercial |
$21,857.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$32,785.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$2,186.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$2,096.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,333.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23,132.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,316.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,866.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,285.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,786.82
|
| Rate for Payer: Multiplan Commercial |
$27,321.33
|
| Rate for Payer: Networks By Design Commercial |
$18,214.22
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$1,333.45
|
| Rate for Payer: Prime Health Services Commercial |
$30,964.17
|
| Rate for Payer: Prime Health Services Medicare |
$1,413.46
|
| Rate for Payer: Riverside University Health System MISP |
$1,466.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21,857.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21,857.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,671.59
|
| Rate for Payer: United Healthcare All Other HMO |
$13,307.31
|
| Rate for Payer: United Healthcare HMO Rider |
$13,019.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,930.31
|
| Rate for Payer: Upland Medical Group Pediatric |
$1,333.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,466.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1,466.80
|
|
|
NUSINERSEN (PF) 28 MG/5 ML INTRATHECAL SOLUTION [249076]
|
Facility
|
IP
|
$36,428.44
|
|
|
Service Code
|
HCPCS J2326
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,285.69 |
| Max. Negotiated Rate |
$32,785.60 |
| Rate for Payer: Adventist Health Commercial |
$7,285.69
|
| Rate for Payer: Blue Shield of California Commercial |
$29,215.61
|
| Rate for Payer: Blue Shield of California EPN |
$18,359.93
|
| Rate for Payer: Cash Price |
$16,392.80
|
| Rate for Payer: Central Health Plan Commercial |
$29,142.75
|
| Rate for Payer: Cigna of CA HMO |
$25,499.91
|
| Rate for Payer: Cigna of CA PPO |
$25,499.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25,499.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$14,571.38
|
| Rate for Payer: EPIC Health Plan Senior |
$14,571.38
|
| Rate for Payer: Galaxy Health WC |
$30,964.17
|
| Rate for Payer: Global Benefits Group Commercial |
$21,857.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$32,785.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23,132.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21,492.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,285.69
|
| Rate for Payer: Multiplan Commercial |
$27,321.33
|
| Rate for Payer: Networks By Design Commercial |
$18,214.22
|
| Rate for Payer: Prime Health Services Commercial |
$30,964.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,671.59
|
| Rate for Payer: United Healthcare All Other HMO |
$13,307.31
|
| Rate for Payer: United Healthcare HMO Rider |
$13,019.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,930.31
|
|
|
NUSINERSEN (PF) 28 MG/5 ML INTRATHECAL SOLUTION [249076]
|
Facility
|
OP
|
$36,428.44
|
|
|
Service Code
|
HCPCS J2326
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,333.45 |
| Max. Negotiated Rate |
$32,785.60 |
| Rate for Payer: Adventist Health Commercial |
$7,285.69
|
| Rate for Payer: Adventist Health Medi-Cal |
$1,333.45
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7,233.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,466.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,466.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2,061.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,572.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1,562.42
|
| Rate for Payer: Blue Shield of California EPN |
$1,420.38
|
| Rate for Payer: Cash Price |
$16,392.80
|
| Rate for Payer: Cash Price |
$16,392.80
|
| Rate for Payer: Central Health Plan Commercial |
$29,142.75
|
| Rate for Payer: Cigna of CA HMO |
$25,499.91
|
| Rate for Payer: Cigna of CA PPO |
$25,499.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,466.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,466.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25,499.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,200.19
|
| Rate for Payer: EPIC Health Plan Senior |
$1,466.80
|
| Rate for Payer: Galaxy Health WC |
$30,964.17
|
| Rate for Payer: Global Benefits Group Commercial |
$21,857.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$32,785.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$2,186.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$2,096.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,333.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23,132.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,316.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,866.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,285.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,786.82
|
| Rate for Payer: Multiplan Commercial |
$27,321.33
|
| Rate for Payer: Networks By Design Commercial |
$18,214.22
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$1,333.45
|
| Rate for Payer: Prime Health Services Commercial |
$30,964.17
|
| Rate for Payer: Prime Health Services Medicare |
$1,413.46
|
| Rate for Payer: Riverside University Health System MISP |
$1,466.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21,857.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21,857.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,671.59
|
| Rate for Payer: United Healthcare All Other HMO |
$13,307.31
|
| Rate for Payer: United Healthcare HMO Rider |
$13,019.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,930.31
|
| Rate for Payer: Upland Medical Group Pediatric |
$1,333.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,466.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1,466.80
|
|
|
NUSINERSEN (PF) 50 MG/5 ML INTRATHECAL SOLUTION [249075]
|
Facility
|
IP
|
$65,050.79
|
|
|
Service Code
|
HCPCS J2326
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13,010.16 |
| Max. Negotiated Rate |
$58,545.71 |
| Rate for Payer: Adventist Health Commercial |
$13,010.16
|
| Rate for Payer: Blue Shield of California Commercial |
$52,170.73
|
| Rate for Payer: Blue Shield of California EPN |
$32,785.60
|
| Rate for Payer: Cash Price |
$29,272.86
|
| Rate for Payer: Central Health Plan Commercial |
$52,040.63
|
| Rate for Payer: Cigna of CA HMO |
$45,535.55
|
| Rate for Payer: Cigna of CA PPO |
$45,535.55
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$45,535.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$26,020.32
|
| Rate for Payer: EPIC Health Plan Senior |
$26,020.32
|
| Rate for Payer: Galaxy Health WC |
$55,293.17
|
| Rate for Payer: Global Benefits Group Commercial |
$39,030.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$58,545.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$41,307.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$38,379.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13,010.16
|
| Rate for Payer: Multiplan Commercial |
$48,788.09
|
| Rate for Payer: Networks By Design Commercial |
$32,525.40
|
| Rate for Payer: Prime Health Services Commercial |
$55,293.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$24,413.56
|
| Rate for Payer: United Healthcare All Other HMO |
$23,763.05
|
| Rate for Payer: United Healthcare HMO Rider |
$23,249.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21,304.13
|
|
