|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 27241-158-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.94
|
| Rate for Payer: Blue Shield of California Commercial |
$3.06
|
| Rate for Payer: Blue Shield of California EPN |
$2.00
|
| Rate for Payer: Cash Price |
$2.75
|
| Rate for Payer: Central Health Plan Commercial |
$4.00
|
| Rate for Payer: Cigna of CA HMO |
$3.50
|
| Rate for Payer: Cigna of CA PPO |
$3.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2.00
|
| Rate for Payer: Galaxy Health WC |
$4.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
| Rate for Payer: Networks By Design Commercial |
$3.25
|
| Rate for Payer: Prime Health Services Commercial |
$4.25
|
| Rate for Payer: Riverside University Health System MISP |
$2.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.50
|
| Rate for Payer: United Healthcare All Other HMO |
$2.50
|
| Rate for Payer: United Healthcare HMO Rider |
$2.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.25
|
| Rate for Payer: Vantage Medical Group Senior |
$4.25
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$4.76
|
|
|
Service Code
|
NDC 65862-753-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.57
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.91
|
| Rate for Payer: Blue Shield of California EPN |
$1.90
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Central Health Plan Commercial |
$3.81
|
| Rate for Payer: Cigna of CA HMO |
$3.33
|
| Rate for Payer: Cigna of CA PPO |
$3.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.90
|
| Rate for Payer: EPIC Health Plan Senior |
$1.90
|
| Rate for Payer: Galaxy Health WC |
$4.05
|
| Rate for Payer: Global Benefits Group Commercial |
$2.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.33
|
| Rate for Payer: Multiplan Commercial |
$3.57
|
| Rate for Payer: Networks By Design Commercial |
$3.09
|
| Rate for Payer: Prime Health Services Commercial |
$4.05
|
| Rate for Payer: Riverside University Health System MISP |
$1.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.38
|
| Rate for Payer: United Healthcare All Other HMO |
$2.38
|
| Rate for Payer: United Healthcare HMO Rider |
$2.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.05
|
| Rate for Payer: Vantage Medical Group Senior |
$4.05
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$19.13
|
|
|
Service Code
|
NDC 68084-965-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.83 |
| Max. Negotiated Rate |
$17.22 |
| Rate for Payer: Adventist Health Commercial |
$3.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$9.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.24
|
| Rate for Payer: Blue Shield of California Commercial |
$11.69
|
| Rate for Payer: Blue Shield of California EPN |
$7.63
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: Central Health Plan Commercial |
$15.30
|
| Rate for Payer: Cigna of CA HMO |
$13.39
|
| Rate for Payer: Cigna of CA PPO |
$13.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.65
|
| Rate for Payer: EPIC Health Plan Senior |
$7.65
|
| Rate for Payer: Galaxy Health WC |
$16.26
|
| Rate for Payer: Global Benefits Group Commercial |
$11.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$17.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.39
|
| Rate for Payer: Multiplan Commercial |
$14.35
|
| Rate for Payer: Networks By Design Commercial |
$12.43
|
| Rate for Payer: Prime Health Services Commercial |
$16.26
|
| Rate for Payer: Riverside University Health System MISP |
$7.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.56
|
| Rate for Payer: United Healthcare All Other HMO |
$9.56
|
| Rate for Payer: United Healthcare HMO Rider |
$9.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.26
|
| Rate for Payer: Vantage Medical Group Senior |
$16.26
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 31722-832-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.94
|
| Rate for Payer: Blue Shield of California Commercial |
$3.06
|
| Rate for Payer: Blue Shield of California EPN |
$2.00
|
| Rate for Payer: Cash Price |
$2.75
|
| Rate for Payer: Central Health Plan Commercial |
$4.00
|
| Rate for Payer: Cigna of CA HMO |
$3.50
|
| Rate for Payer: Cigna of CA PPO |
$3.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2.00
|
| Rate for Payer: Galaxy Health WC |
$4.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
| Rate for Payer: Networks By Design Commercial |
$3.25
|
| Rate for Payer: Prime Health Services Commercial |
$4.25
|
| Rate for Payer: Riverside University Health System MISP |
$2.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.50
|
| Rate for Payer: United Healthcare All Other HMO |
$2.50
|
| Rate for Payer: United Healthcare HMO Rider |
$2.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.25
|
| Rate for Payer: Vantage Medical Group Senior |
$4.25
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$106.08
|
|
|
Service Code
|
NDC 0004-0038-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.22 |
| Max. Negotiated Rate |
$95.47 |
| Rate for Payer: Adventist Health Commercial |
$21.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$64.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$79.56
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$51.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$62.30
|
| Rate for Payer: Blue Shield of California Commercial |
$64.81
|
| Rate for Payer: Blue Shield of California EPN |
$42.33
|
| Rate for Payer: Cash Price |
$58.35
|
| Rate for Payer: Central Health Plan Commercial |
$84.86
|
| Rate for Payer: Cigna of CA HMO |
$74.26
|
| Rate for Payer: Cigna of CA PPO |
$74.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$90.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.43
|
| Rate for Payer: EPIC Health Plan Senior |
$42.43
|
| Rate for Payer: Galaxy Health WC |
$90.17
|
| Rate for Payer: Global Benefits Group Commercial |
$63.65
|
| Rate for Payer: Health Management Network EPO/PPO |
$95.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$70.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$40.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$65.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74.26
|
| Rate for Payer: Multiplan Commercial |
$79.56
|
| Rate for Payer: Networks By Design Commercial |
$68.95
|
| Rate for Payer: Prime Health Services Commercial |
$90.17
|
| Rate for Payer: Riverside University Health System MISP |
$42.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$63.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$63.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$53.04
|
| Rate for Payer: United Healthcare All Other HMO |
$53.04
|
| Rate for Payer: United Healthcare HMO Rider |
$53.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$53.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$90.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.17
|
| Rate for Payer: Vantage Medical Group Senior |
$90.17
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
IP
|
$106.08
|
|
|
Service Code
|
NDC 0004-0038-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.22 |
| Max. Negotiated Rate |
$95.47 |
| Rate for Payer: Adventist Health Commercial |
$21.22
|
| Rate for Payer: Blue Shield of California Commercial |
$82.00
|
| Rate for Payer: Blue Shield of California EPN |
$53.46
|
| Rate for Payer: Cash Price |
$58.35
|
| Rate for Payer: Central Health Plan Commercial |
$84.86
|
| Rate for Payer: Cigna of CA HMO |
$74.26
|
| Rate for Payer: Cigna of CA PPO |
$74.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.43
|
| Rate for Payer: EPIC Health Plan Senior |
$42.43
|
| Rate for Payer: Galaxy Health WC |
$90.17
|
| Rate for Payer: Global Benefits Group Commercial |
$63.65
|
| Rate for Payer: Health Management Network EPO/PPO |
$95.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$70.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$40.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$65.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.22
|
| Rate for Payer: Multiplan Commercial |
$79.56
|
| Rate for Payer: Networks By Design Commercial |
$68.95
|
| Rate for Payer: Prime Health Services Commercial |
$90.17
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$28.11
|
|
|
Service Code
|
NDC 55111-762-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.62 |
| Max. Negotiated Rate |
$25.30 |
| Rate for Payer: Adventist Health Commercial |
$5.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$17.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.51
|
| Rate for Payer: Blue Shield of California Commercial |
$17.18
|
| Rate for Payer: Blue Shield of California EPN |
$11.22
|
| Rate for Payer: Cash Price |
$15.46
|
| Rate for Payer: Central Health Plan Commercial |
$22.49
|
| Rate for Payer: Cigna of CA HMO |
$19.68
|
| Rate for Payer: Cigna of CA PPO |
$19.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$23.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.24
|
| Rate for Payer: EPIC Health Plan Senior |
$11.24
|
| Rate for Payer: Galaxy Health WC |
$23.89
|
| Rate for Payer: Global Benefits Group Commercial |
$16.87
|
| Rate for Payer: Health Management Network EPO/PPO |
$25.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$18.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19.68
|
| Rate for Payer: Multiplan Commercial |
$21.08
|
| Rate for Payer: Networks By Design Commercial |
$18.27
|
| Rate for Payer: Prime Health Services Commercial |
$23.89
|
| Rate for Payer: Riverside University Health System MISP |
$11.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.05
|
| Rate for Payer: United Healthcare All Other HMO |
$14.05
|
| Rate for Payer: United Healthcare HMO Rider |
$14.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.89
|
| Rate for Payer: Vantage Medical Group Senior |
$23.89
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 31722-832-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3.87
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Cash Price |
$2.75
|
| Rate for Payer: Central Health Plan Commercial |
$4.00
|
| Rate for Payer: Cigna of CA HMO |
$3.50
|
| Rate for Payer: Cigna of CA PPO |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2.00
|
| Rate for Payer: Galaxy Health WC |
$4.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
| Rate for Payer: Networks By Design Commercial |
$3.25
|
| Rate for Payer: Prime Health Services Commercial |
$4.25
|
|
|
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION [99443]
|
Facility
|
OP
|
$10.91
|
|
|
Service Code
|
NDC 0591-2579-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$9.82 |
| Rate for Payer: Adventist Health Commercial |
$2.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.41
|
| Rate for Payer: Blue Shield of California Commercial |
$6.67
|
| Rate for Payer: Blue Shield of California EPN |
$4.35
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Central Health Plan Commercial |
$8.73
|
| Rate for Payer: Cigna of CA HMO |
$7.64
|
| Rate for Payer: Cigna of CA PPO |
$7.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.36
|
| Rate for Payer: EPIC Health Plan Senior |
$4.36
|
| Rate for Payer: Galaxy Health WC |
$9.27
|
| Rate for Payer: Global Benefits Group Commercial |
$6.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$9.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.64
|
| Rate for Payer: Multiplan Commercial |
$8.18
|
| Rate for Payer: Networks By Design Commercial |
$7.09
|
| Rate for Payer: Prime Health Services Commercial |
$9.27
|
| Rate for Payer: Riverside University Health System MISP |
$4.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.46
|
| Rate for Payer: United Healthcare All Other HMO |
$5.46
|
| Rate for Payer: United Healthcare HMO Rider |
$5.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.27
|
| Rate for Payer: Vantage Medical Group Senior |
$9.27
|
|
|
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION [99443]
|
Facility
|
IP
|
$10.91
|
|
|
Service Code
|
NDC 70010-051-40
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$9.82 |
| Rate for Payer: Adventist Health Commercial |
$2.18
|
| Rate for Payer: Blue Shield of California Commercial |
$8.43
|
| Rate for Payer: Blue Shield of California EPN |
$5.50
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Central Health Plan Commercial |
$8.73
|
| Rate for Payer: Cigna of CA HMO |
$7.64
|
| Rate for Payer: Cigna of CA PPO |
$7.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.36
|
| Rate for Payer: EPIC Health Plan Senior |
$4.36
|
| Rate for Payer: Galaxy Health WC |
$9.27
|
| Rate for Payer: Global Benefits Group Commercial |
$6.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$9.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$8.18
|
| Rate for Payer: Networks By Design Commercial |
$7.09
|
| Rate for Payer: Prime Health Services Commercial |
$9.27
|
|
|
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION [99443]
|
Facility
|
OP
|
$10.91
|
|
|
Service Code
|
NDC 70010-051-40
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$9.82 |
| Rate for Payer: Adventist Health Commercial |
$2.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.41
|
| Rate for Payer: Blue Shield of California Commercial |
$6.67
|
| Rate for Payer: Blue Shield of California EPN |
$4.35
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Central Health Plan Commercial |
$8.73
|
| Rate for Payer: Cigna of CA HMO |
$7.64
|
| Rate for Payer: Cigna of CA PPO |
$7.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.36
|
| Rate for Payer: EPIC Health Plan Senior |
$4.36
|
| Rate for Payer: Galaxy Health WC |
$9.27
|
| Rate for Payer: Global Benefits Group Commercial |
$6.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$9.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.64
|
| Rate for Payer: Multiplan Commercial |
$8.18
|
| Rate for Payer: Networks By Design Commercial |
$7.09
|
| Rate for Payer: Prime Health Services Commercial |
$9.27
|
| Rate for Payer: Riverside University Health System MISP |
$4.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.46
|
| Rate for Payer: United Healthcare All Other HMO |
$5.46
|
| Rate for Payer: United Healthcare HMO Rider |
$5.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.27
|
| Rate for Payer: Vantage Medical Group Senior |
$9.27
|
|
|
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION [99443]
|
Facility
|
IP
|
$10.91
|
|
|
Service Code
|
NDC 0591-2579-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$9.82 |
| Rate for Payer: Adventist Health Commercial |
$2.18
|
| Rate for Payer: Blue Shield of California Commercial |
$8.43
|
| Rate for Payer: Blue Shield of California EPN |
$5.50
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Central Health Plan Commercial |
$8.73
|
| Rate for Payer: Cigna of CA HMO |
$7.64
|
| Rate for Payer: Cigna of CA PPO |
$7.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.36
|
| Rate for Payer: EPIC Health Plan Senior |
$4.36
|
| Rate for Payer: Galaxy Health WC |
$9.27
|
| Rate for Payer: Global Benefits Group Commercial |
$6.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$9.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$8.18
|
| Rate for Payer: Networks By Design Commercial |
$7.09
|
| Rate for Payer: Prime Health Services Commercial |
$9.27
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 63323-494-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.95
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Central Health Plan Commercial |
$1.29
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA PPO |
$1.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Senior |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.97
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.37
|
| Rate for Payer: Riverside University Health System MISP |
$0.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.97
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO |
$0.81
|
| Rate for Payer: United Healthcare HMO Rider |
$0.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Vantage Medical Group Senior |
$1.37
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
|
IP
|
$1.61
|
|
|
Service Code
|
NDC 63323-494-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.81
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Central Health Plan Commercial |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Senior |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.97
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.37
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 63323-494-16
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
| Rate for Payer: Riverside University Health System MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 25021-797-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.25
|
| Rate for Payer: Cigna of CA HMO |
$1.00
|
| Rate for Payer: Cigna of CA PPO |
$1.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
| Rate for Payer: Riverside University Health System MISP |
$0.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.78
|
| Rate for Payer: United Healthcare All Other HMO |
$0.78
|
| Rate for Payer: United Healthcare HMO Rider |
$0.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 25021-797-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
|
IP
|
$1.68
|
|
|
Service Code
|
NDC 0143-9785-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Central Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: EPIC Health Plan Senior |
$0.67
|
| Rate for Payer: Galaxy Health WC |
$1.43
|
| Rate for Payer: Global Benefits Group Commercial |
$1.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.51
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Networks By Design Commercial |
$1.09
|
| Rate for Payer: Prime Health Services Commercial |
$1.43
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 63323-494-41
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
|
IP
|
$1.68
|
|
|
Service Code
|
NDC 0143-9785-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Central Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: EPIC Health Plan Senior |
$0.67
|
| Rate for Payer: Galaxy Health WC |
$1.43
|
| Rate for Payer: Global Benefits Group Commercial |
$1.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.51
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Networks By Design Commercial |
$1.09
|
| Rate for Payer: Prime Health Services Commercial |
$1.43
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
|
OP
|
$1.68
|
|
|
Service Code
|
NDC 0143-9785-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.99
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Central Health Plan Commercial |
$1.34
|
| Rate for Payer: Cigna of CA HMO |
$1.08
|
| Rate for Payer: Cigna of CA PPO |
$1.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: EPIC Health Plan Senior |
$0.67
|
| Rate for Payer: Galaxy Health WC |
$1.43
|
| Rate for Payer: Global Benefits Group Commercial |
$1.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.51
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.18
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Networks By Design Commercial |
$1.09
|
| Rate for Payer: Prime Health Services Commercial |
$1.43
|
| Rate for Payer: Riverside University Health System MISP |
$0.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.84
|
| Rate for Payer: United Healthcare All Other HMO |
$0.84
|
| Rate for Payer: United Healthcare HMO Rider |
$0.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: Vantage Medical Group Senior |
$1.43
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
|
IP
|
$1.61
|
|
|
Service Code
|
NDC 63323-494-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.81
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Central Health Plan Commercial |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Senior |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.97
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.37
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
|
OP
|
$1.68
|
|
|
Service Code
|
NDC 0143-9785-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.99
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Central Health Plan Commercial |
$1.34
|
| Rate for Payer: Cigna of CA HMO |
$1.08
|
| Rate for Payer: Cigna of CA PPO |
$1.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: EPIC Health Plan Senior |
$0.67
|
| Rate for Payer: Galaxy Health WC |
$1.43
|
| Rate for Payer: Global Benefits Group Commercial |
$1.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.51
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.18
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Networks By Design Commercial |
$1.09
|
| Rate for Payer: Prime Health Services Commercial |
$1.43
|
| Rate for Payer: Riverside University Health System MISP |
$0.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.84
|
| Rate for Payer: United Healthcare All Other HMO |
$0.84
|
| Rate for Payer: United Healthcare HMO Rider |
$0.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: Vantage Medical Group Senior |
$1.43
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 63323-494-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.95
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Central Health Plan Commercial |
$1.29
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA PPO |
$1.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Senior |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.97
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.37
|
| Rate for Payer: Riverside University Health System MISP |
$0.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.97
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO |
$0.81
|
| Rate for Payer: United Healthcare HMO Rider |
$0.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Vantage Medical Group Senior |
$1.37
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 63323-494-16
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
|
