|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 62332-246-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.43
|
| Rate for Payer: InnovAge PACE Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA 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 |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
| Rate for Payer: Riverside University Health System MISP |
$0.19
|
| 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 |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 68382-512-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.73
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.57
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Central Health Plan Commercial |
$0.78
|
| Rate for Payer: Cigna of CA HMO |
$0.68
|
| Rate for Payer: Cigna of CA PPO |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: EPIC Health Plan Senior |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.87
|
| Rate for Payer: InnovAge PACE Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
| Rate for Payer: Riverside University Health System MISP |
$0.39
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO |
$0.49
|
| Rate for Payer: United Healthcare HMO Rider |
$0.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 68382-512-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Central Health Plan Commercial |
$0.78
|
| Rate for Payer: Cigna of CA HMO |
$0.68
|
| Rate for Payer: Cigna of CA PPO |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: EPIC Health Plan Senior |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 16571-834-01
|
| 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 |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$2.18
|
|
|
Service Code
|
NDC 60687-422-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.64
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Central Health Plan Commercial |
$1.74
|
| Rate for Payer: Cigna of CA HMO |
$1.53
|
| Rate for Payer: Cigna of CA PPO |
$1.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.87
|
| Rate for Payer: EPIC Health Plan Senior |
$0.87
|
| Rate for Payer: Galaxy Health WC |
$1.85
|
| Rate for Payer: Global Benefits Group Commercial |
$1.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.96
|
| Rate for Payer: InnovAge PACE Commercial |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
| Rate for Payer: Networks By Design Commercial |
$1.42
|
| Rate for Payer: Prime Health Services Commercial |
$1.85
|
| Rate for Payer: Riverside University Health System MISP |
$0.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.09
|
| Rate for Payer: United Healthcare All Other HMO |
$1.09
|
| Rate for Payer: United Healthcare HMO Rider |
$1.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1.85
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 62332-246-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| 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 |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 60687-797-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 0121-0646-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 60687-797-42
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 0121-0646-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| 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 |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.06
|
| Rate for Payer: InnovAge PACE Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Riverside University Health System MISP |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 60687-797-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| 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 |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| 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 |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| Rate for Payer: InnovAge PACE Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Riverside University Health System MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.30
|
| 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 |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 60687-797-42
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| 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 |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| 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 |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| Rate for Payer: InnovAge PACE Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Riverside University Health System MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.30
|
| 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 |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
OP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0802-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$494.87 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$333.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$467.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$302.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$412.39
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$266.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$322.93
|
| Rate for Payer: Blue Shield of California Commercial |
$335.96
|
| Rate for Payer: Blue Shield of California EPN |
$219.39
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Central Health Plan Commercial |
$439.88
|
| Rate for Payer: Cigna of CA HMO |
$384.89
|
| Rate for Payer: Cigna of CA PPO |
$384.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$467.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$467.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$467.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.37
|
| Rate for Payer: Global Benefits Group Commercial |
$329.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$494.87
|
| Rate for Payer: InnovAge PACE Commercial |
$274.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.89
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
| Rate for Payer: Networks By Design Commercial |
$357.40
|
| Rate for Payer: Prime Health Services Commercial |
$467.37
|
| Rate for Payer: Riverside University Health System MISP |
$219.94
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$329.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$329.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$274.93
|
| Rate for Payer: United Healthcare All Other HMO |
$274.93
|
| Rate for Payer: United Healthcare HMO Rider |
$274.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$274.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$467.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$467.37
|
| Rate for Payer: Vantage Medical Group Senior |
$467.37
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
OP
|
$46.08
|
|
|
Service Code
|
NDC 47335-237-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$41.47 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.56
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$22.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.06
|
| Rate for Payer: Blue Shield of California Commercial |
$28.15
|
| Rate for Payer: Blue Shield of California EPN |
$18.39
|
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: Central Health Plan Commercial |
$36.86
|
| Rate for Payer: Cigna of CA HMO |
$32.26
|
| Rate for Payer: Cigna of CA PPO |
$32.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.43
|
| Rate for Payer: EPIC Health Plan Senior |
$18.43
|
| Rate for Payer: Galaxy Health WC |
$39.17
|
| Rate for Payer: Global Benefits Group Commercial |
$27.65
|
| Rate for Payer: Health Management Network EPO/PPO |
$41.47
|
| Rate for Payer: InnovAge PACE Commercial |
$23.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.26
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
| Rate for Payer: Networks By Design Commercial |
$29.95
|
| Rate for Payer: Prime Health Services Commercial |
$39.17
|
| Rate for Payer: Riverside University Health System MISP |
$18.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.04
|
| Rate for Payer: United Healthcare All Other HMO |
$23.04
|
| Rate for Payer: United Healthcare HMO Rider |
$23.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.17
|
| Rate for Payer: Vantage Medical Group Senior |
$39.17
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$46.08
|
|
|
Service Code
|
NDC 47335-237-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$41.47 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Blue Shield of California Commercial |
$35.62
|
| Rate for Payer: Blue Shield of California EPN |
$23.22
|
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: Central Health Plan Commercial |
$36.86
|
| Rate for Payer: Cigna of CA HMO |
$32.26
|
| Rate for Payer: Cigna of CA PPO |
$32.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.43
|
| Rate for Payer: EPIC Health Plan Senior |
$18.43
|
| Rate for Payer: Galaxy Health WC |
$39.17
|
| Rate for Payer: Global Benefits Group Commercial |
$27.65
|
| Rate for Payer: Health Management Network EPO/PPO |
$41.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.22
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
| Rate for Payer: Networks By Design Commercial |
$29.95
|
| Rate for Payer: Prime Health Services Commercial |
$39.17
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0802-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$494.87 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Blue Shield of California Commercial |
$425.03
|
| Rate for Payer: Blue Shield of California EPN |
$277.12
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Central Health Plan Commercial |
$439.88
|
| Rate for Payer: Cigna of CA HMO |
$384.89
|
| Rate for Payer: Cigna of CA PPO |
$384.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.37
|
| Rate for Payer: Global Benefits Group Commercial |
$329.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$494.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.97
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
| Rate for Payer: Networks By Design Commercial |
$357.40
|
| Rate for Payer: Prime Health Services Commercial |
$467.37
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
OP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0802-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$494.87 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$333.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$467.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$302.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$412.39
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$266.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$322.93
|
| Rate for Payer: Blue Shield of California Commercial |
$335.96
|
| Rate for Payer: Blue Shield of California EPN |
$219.39
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Central Health Plan Commercial |
$439.89
|
| Rate for Payer: Cigna of CA HMO |
$384.90
|
| Rate for Payer: Cigna of CA PPO |
$384.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$467.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$467.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$467.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.38
|
| Rate for Payer: Global Benefits Group Commercial |
$329.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$494.87
|
| Rate for Payer: InnovAge PACE Commercial |
$274.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.90
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
| Rate for Payer: Networks By Design Commercial |
$357.41
|
| Rate for Payer: Prime Health Services Commercial |
$467.38
|
| Rate for Payer: Riverside University Health System MISP |
$219.94
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$329.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$329.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$274.93
|
| Rate for Payer: United Healthcare All Other HMO |
$274.93
|
| Rate for Payer: United Healthcare HMO Rider |
$274.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$274.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$467.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$467.38
|
| Rate for Payer: Vantage Medical Group Senior |
$467.38
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0802-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$494.87 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Blue Shield of California Commercial |
$425.04
|
| Rate for Payer: Blue Shield of California EPN |
$277.13
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Central Health Plan Commercial |
$439.89
|
| Rate for Payer: Cigna of CA HMO |
$384.90
|
| Rate for Payer: Cigna of CA PPO |
$384.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.38
|
| Rate for Payer: Global Benefits Group Commercial |
$329.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$494.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.97
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
| Rate for Payer: Networks By Design Commercial |
$357.41
|
| Rate for Payer: Prime Health Services Commercial |
$467.38
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$46.08
|
|
|
Service Code
|
NDC 47335-236-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$41.47 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.56
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$22.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.06
|
| Rate for Payer: Blue Shield of California Commercial |
$28.15
|
| Rate for Payer: Blue Shield of California EPN |
$18.39
|
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: Central Health Plan Commercial |
$36.86
|
| Rate for Payer: Cigna of CA HMO |
$32.26
|
| Rate for Payer: Cigna of CA PPO |
$32.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.43
|
| Rate for Payer: EPIC Health Plan Senior |
$18.43
|
| Rate for Payer: Galaxy Health WC |
$39.17
|
| Rate for Payer: Global Benefits Group Commercial |
$27.65
|
| Rate for Payer: Health Management Network EPO/PPO |
$41.47
|
| Rate for Payer: InnovAge PACE Commercial |
$23.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.26
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
| Rate for Payer: Networks By Design Commercial |
$29.95
|
| Rate for Payer: Prime Health Services Commercial |
$39.17
|
| Rate for Payer: Riverside University Health System MISP |
$18.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.04
|
| Rate for Payer: United Healthcare All Other HMO |
$23.04
|
| Rate for Payer: United Healthcare HMO Rider |
$23.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.17
|
| Rate for Payer: Vantage Medical Group Senior |
$39.17
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0801-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$494.87 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Blue Shield of California Commercial |
$425.03
|
| Rate for Payer: Blue Shield of California EPN |
$277.12
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Central Health Plan Commercial |
$439.88
|
| Rate for Payer: Cigna of CA HMO |
$384.89
|
| Rate for Payer: Cigna of CA PPO |
$384.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.37
|
| Rate for Payer: Global Benefits Group Commercial |
$329.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$494.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.97
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
| Rate for Payer: Networks By Design Commercial |
$357.40
|
| Rate for Payer: Prime Health Services Commercial |
$467.37
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0801-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$494.87 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Blue Shield of California Commercial |
$425.04
|
| Rate for Payer: Blue Shield of California EPN |
$277.13
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Central Health Plan Commercial |
$439.89
|
| Rate for Payer: Cigna of CA HMO |
$384.90
|
| Rate for Payer: Cigna of CA PPO |
$384.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.38
|
| Rate for Payer: Global Benefits Group Commercial |
$329.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$494.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.97
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
| Rate for Payer: Networks By Design Commercial |
$357.41
|
| Rate for Payer: Prime Health Services Commercial |
$467.38
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$46.08
|
|
|
Service Code
|
NDC 47335-236-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$41.47 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Blue Shield of California Commercial |
$35.62
|
| Rate for Payer: Blue Shield of California EPN |
$23.22
|
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: Central Health Plan Commercial |
$36.86
|
| Rate for Payer: Cigna of CA HMO |
$32.26
|
| Rate for Payer: Cigna of CA PPO |
$32.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.43
|
| Rate for Payer: EPIC Health Plan Senior |
$18.43
|
| Rate for Payer: Galaxy Health WC |
$39.17
|
| Rate for Payer: Global Benefits Group Commercial |
$27.65
|
| Rate for Payer: Health Management Network EPO/PPO |
$41.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.22
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
| Rate for Payer: Networks By Design Commercial |
$29.95
|
| Rate for Payer: Prime Health Services Commercial |
$39.17
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0801-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$494.87 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$333.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$467.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$302.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$412.39
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$266.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$322.93
|
| Rate for Payer: Blue Shield of California Commercial |
$335.96
|
| Rate for Payer: Blue Shield of California EPN |
$219.39
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Central Health Plan Commercial |
$439.88
|
| Rate for Payer: Cigna of CA HMO |
$384.89
|
| Rate for Payer: Cigna of CA PPO |
$384.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$467.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$467.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$467.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.37
|
| Rate for Payer: Global Benefits Group Commercial |
$329.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$494.87
|
| Rate for Payer: InnovAge PACE Commercial |
$274.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.89
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
| Rate for Payer: Networks By Design Commercial |
$357.40
|
| Rate for Payer: Prime Health Services Commercial |
$467.37
|
| Rate for Payer: Riverside University Health System MISP |
$219.94
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$329.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$329.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$274.93
|
| Rate for Payer: United Healthcare All Other HMO |
$274.93
|
| Rate for Payer: United Healthcare HMO Rider |
$274.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$274.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$467.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$467.37
|
| Rate for Payer: Vantage Medical Group Senior |
$467.37
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0801-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$494.87 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$333.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$467.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$302.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$412.39
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$266.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$322.93
|
| Rate for Payer: Blue Shield of California Commercial |
$335.96
|
| Rate for Payer: Blue Shield of California EPN |
$219.39
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Central Health Plan Commercial |
$439.89
|
| Rate for Payer: Cigna of CA HMO |
$384.90
|
| Rate for Payer: Cigna of CA PPO |
$384.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$467.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$467.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$467.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.38
|
| Rate for Payer: Global Benefits Group Commercial |
$329.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$494.87
|
| Rate for Payer: InnovAge PACE Commercial |
$274.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.90
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
| Rate for Payer: Networks By Design Commercial |
$357.41
|
| Rate for Payer: Prime Health Services Commercial |
$467.38
|
| Rate for Payer: Riverside University Health System MISP |
$219.94
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$329.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$329.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$274.93
|
| Rate for Payer: United Healthcare All Other HMO |
$274.93
|
| Rate for Payer: United Healthcare HMO Rider |
$274.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$274.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$467.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$467.38
|
| Rate for Payer: Vantage Medical Group Senior |
$467.38
|
|
|
AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Blue Shield of California Commercial |
$2.05
|
| Rate for Payer: Blue Shield of California Commercial |
$2.05
|
| Rate for Payer: Blue Shield of California Commercial |
$2.05
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Central Health Plan Commercial |
$5.59
|
| Rate for Payer: Central Health Plan Commercial |
$3.84
|
| Rate for Payer: Central Health Plan Commercial |
$3.43
|
| Rate for Payer: Cigna of CA HMO |
$4.89
|
| Rate for Payer: Cigna of CA HMO |
$3.36
|
| Rate for Payer: Cigna of CA HMO |
$3.00
|
| Rate for Payer: Cigna of CA PPO |
$3.00
|
| Rate for Payer: Cigna of CA PPO |
$4.89
|
| Rate for Payer: Cigna of CA PPO |
$3.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1.72
|
| Rate for Payer: EPIC Health Plan Senior |
$1.92
|
| Rate for Payer: EPIC Health Plan Senior |
$2.80
|
| Rate for Payer: Galaxy Health WC |
$5.94
|
| Rate for Payer: Galaxy Health WC |
$3.65
|
| Rate for Payer: Galaxy Health WC |
$4.08
|
| Rate for Payer: Global Benefits Group Commercial |
$2.57
|
| Rate for Payer: Global Benefits Group Commercial |
$4.19
|
| Rate for Payer: Global Benefits Group Commercial |
$2.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.60
|
| Rate for Payer: InnovAge PACE Commercial |
$3.50
|
| Rate for Payer: InnovAge PACE Commercial |
$2.40
|
| Rate for Payer: InnovAge PACE Commercial |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.89
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Networks By Design Commercial |
$2.15
|
| Rate for Payer: Networks By Design Commercial |
$3.50
|
| Rate for Payer: Networks By Design Commercial |
$2.40
|
| Rate for Payer: Prime Health Services Commercial |
$4.08
|
| Rate for Payer: Prime Health Services Commercial |
$5.94
|
| Rate for Payer: Prime Health Services Commercial |
$3.65
|
| Rate for Payer: Riverside University Health System MISP |
$2.80
|
| Rate for Payer: Riverside University Health System MISP |
$1.92
|
| Rate for Payer: Riverside University Health System MISP |
$1.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.61
|
| Rate for Payer: United Healthcare All Other HMO |
$1.57
|
| Rate for Payer: United Healthcare All Other HMO |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO |
$2.55
|
| Rate for Payer: United Healthcare HMO Rider |
$1.72
|
| Rate for Payer: United Healthcare HMO Rider |
$1.53
|
| Rate for Payer: United Healthcare HMO Rider |
$2.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$3.65
|
| Rate for Payer: Vantage Medical Group Senior |
$5.94
|
|
