|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 0832101500
|
| 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 |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.44
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 6838251201
|
| 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 |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.44
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 6068779756
|
| 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 |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| 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/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
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 6068779756
|
| 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 |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.32
|
| 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 |
$0.38
|
| 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
|
$0.50
|
|
|
Service Code
|
NDC 6068779742
|
| 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 |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| 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/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
|
$0.07
|
|
|
Service Code
|
NDC 0121064616
|
| 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 |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 0121064616
|
| 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 |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals 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 6068779742
|
| 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 |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.32
|
| 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 |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$46.08
|
|
|
Service Code
|
NDC 4733523783
|
| 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 |
$36.96
|
| Rate for Payer: Blue Shield of California EPN |
$23.22
|
| Rate for Payer: Cash Price |
$20.74
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$29.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.19
|
| 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
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 5965149530
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.44
|
| Rate for Payer: Blue Shield of California Commercial |
$2.66
|
| Rate for Payer: Blue Shield of California EPN |
$1.68
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Central Health Plan Commercial |
$3.36
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Senior |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
| Rate for Payer: Riverside University Health System MISP |
$1.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.10
|
| Rate for Payer: United Healthcare All Other HMO |
$2.10
|
| Rate for Payer: United Healthcare HMO Rider |
$2.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$46.08
|
|
|
Service Code
|
NDC 0378427193
|
| 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 |
$36.96
|
| Rate for Payer: Blue Shield of California EPN |
$23.22
|
| Rate for Payer: Cash Price |
$20.74
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$29.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.19
|
| 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
|
$4.20
|
|
|
Service Code
|
NDC 5965149530
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$3.37
|
| Rate for Payer: Blue Shield of California EPN |
$2.12
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Central Health Plan Commercial |
$3.36
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Senior |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
OP
|
$46.08
|
|
|
Service Code
|
NDC 0378427193
|
| 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 |
$26.80
|
| Rate for Payer: Blue Shield of California Commercial |
$29.21
|
| Rate for Payer: Blue Shield of California EPN |
$18.39
|
| Rate for Payer: Cash Price |
$20.74
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$29.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$46.08
|
|
|
Service Code
|
NDC 4733523783
|
| 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 |
$26.80
|
| Rate for Payer: Blue Shield of California Commercial |
$29.21
|
| Rate for Payer: Blue Shield of California EPN |
$18.39
|
| Rate for Payer: Cash Price |
$20.74
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$29.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 5965149430
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.44
|
| Rate for Payer: Blue Shield of California Commercial |
$2.66
|
| Rate for Payer: Blue Shield of California EPN |
$1.68
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Central Health Plan Commercial |
$3.36
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Senior |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
| Rate for Payer: Riverside University Health System MISP |
$1.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.10
|
| Rate for Payer: United Healthcare All Other HMO |
$2.10
|
| Rate for Payer: United Healthcare HMO Rider |
$2.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 5965149430
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$3.37
|
| Rate for Payer: Blue Shield of California EPN |
$2.12
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Central Health Plan Commercial |
$3.36
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Senior |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$582.30
|
|
|
Service Code
|
NDC 6195808015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$116.46 |
| Max. Negotiated Rate |
$524.07 |
| Rate for Payer: Adventist Health Commercial |
$116.46
|
| Rate for Payer: Aetna of CA HMO/PPO |
$353.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$494.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$320.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$436.73
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$281.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$338.72
|
| Rate for Payer: Blue Shield of California Commercial |
$369.18
|
| Rate for Payer: Blue Shield of California EPN |
$232.34
|
| Rate for Payer: Cash Price |
$262.03
|
| Rate for Payer: Central Health Plan Commercial |
$465.84
|
| Rate for Payer: Cigna of CA HMO |
$407.61
|
| Rate for Payer: Cigna of CA PPO |
$407.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$494.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$494.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$494.95
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$407.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$232.92
|
| Rate for Payer: EPIC Health Plan Senior |
$232.92
|
| Rate for Payer: Galaxy Health WC |
$494.95
|
| Rate for Payer: Global Benefits Group Commercial |
$349.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$524.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$369.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$211.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$343.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$407.61
|
| Rate for Payer: Multiplan Commercial |
$436.73
|
| Rate for Payer: Networks By Design Commercial |
$378.50
|
| Rate for Payer: Prime Health Services Commercial |
$494.95
|
| Rate for Payer: Riverside University Health System MISP |
$232.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$349.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$349.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$291.15
|
| Rate for Payer: United Healthcare All Other HMO |
$291.15
|
| Rate for Payer: United Healthcare HMO Rider |
$291.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$291.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$494.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$494.95
|
| Rate for Payer: Vantage Medical Group Senior |
$494.95
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$582.30
|
|
|
Service Code
|
NDC 6195808015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$116.46 |
| Max. Negotiated Rate |
$524.07 |
| Rate for Payer: Adventist Health Commercial |
$116.46
|
| Rate for Payer: Blue Shield of California Commercial |
$467.00
|
| Rate for Payer: Blue Shield of California EPN |
$293.48
|
| Rate for Payer: Cash Price |
$262.03
|
| Rate for Payer: Central Health Plan Commercial |
$465.84
|
| Rate for Payer: Cigna of CA HMO |
$407.61
|
| Rate for Payer: Cigna of CA PPO |
$407.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$407.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$232.92
|
| Rate for Payer: EPIC Health Plan Senior |
$232.92
|
| Rate for Payer: Galaxy Health WC |
$494.95
|
| Rate for Payer: Global Benefits Group Commercial |
$349.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$524.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$369.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$343.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.46
|
| Rate for Payer: Multiplan Commercial |
$436.73
|
| Rate for Payer: Networks By Design Commercial |
$378.50
|
| Rate for Payer: Prime Health Services Commercial |
$494.95
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$582.30
|
|
|
Service Code
|
NDC 6195808011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$116.46 |
| Max. Negotiated Rate |
$524.07 |
| Rate for Payer: Adventist Health Commercial |
$116.46
|
| Rate for Payer: Blue Shield of California Commercial |
$467.00
|
| Rate for Payer: Blue Shield of California EPN |
$293.48
|
| Rate for Payer: Cash Price |
$262.03
|
| Rate for Payer: Central Health Plan Commercial |
$465.84
|
| Rate for Payer: Cigna of CA HMO |
$407.61
|
| Rate for Payer: Cigna of CA PPO |
$407.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$407.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$232.92
|
| Rate for Payer: EPIC Health Plan Senior |
$232.92
|
| Rate for Payer: Galaxy Health WC |
$494.95
|
| Rate for Payer: Global Benefits Group Commercial |
$349.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$524.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$369.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$343.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.46
|
| Rate for Payer: Multiplan Commercial |
$436.73
|
| Rate for Payer: Networks By Design Commercial |
$378.50
|
| Rate for Payer: Prime Health Services Commercial |
$494.95
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$46.08
|
|
|
Service Code
|
NDC 4733523683
|
| 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 |
$36.96
|
| Rate for Payer: Blue Shield of California EPN |
$23.22
|
| Rate for Payer: Cash Price |
$20.74
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$29.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.19
|
| 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
|
$582.30
|
|
|
Service Code
|
NDC 6195808011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$116.46 |
| Max. Negotiated Rate |
$524.07 |
| Rate for Payer: Adventist Health Commercial |
$116.46
|
| Rate for Payer: Aetna of CA HMO/PPO |
$353.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$494.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$320.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$436.73
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$281.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$338.72
|
| Rate for Payer: Blue Shield of California Commercial |
$369.18
|
| Rate for Payer: Blue Shield of California EPN |
$232.34
|
| Rate for Payer: Cash Price |
$262.03
|
| Rate for Payer: Central Health Plan Commercial |
$465.84
|
| Rate for Payer: Cigna of CA HMO |
$407.61
|
| Rate for Payer: Cigna of CA PPO |
$407.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$494.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$494.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$494.95
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$407.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$232.92
|
| Rate for Payer: EPIC Health Plan Senior |
$232.92
|
| Rate for Payer: Galaxy Health WC |
$494.95
|
| Rate for Payer: Global Benefits Group Commercial |
$349.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$524.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$369.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$211.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$343.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$407.61
|
| Rate for Payer: Multiplan Commercial |
$436.73
|
| Rate for Payer: Networks By Design Commercial |
$378.50
|
| Rate for Payer: Prime Health Services Commercial |
$494.95
|
| Rate for Payer: Riverside University Health System MISP |
$232.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$349.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$349.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$291.15
|
| Rate for Payer: United Healthcare All Other HMO |
$291.15
|
| Rate for Payer: United Healthcare HMO Rider |
$291.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$291.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$494.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$494.95
|
| Rate for Payer: Vantage Medical Group Senior |
$494.95
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$46.08
|
|
|
Service Code
|
NDC 4733523683
|
| 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 |
$26.80
|
| Rate for Payer: Blue Shield of California Commercial |
$29.21
|
| Rate for Payer: Blue Shield of California EPN |
$18.39
|
| Rate for Payer: Cash Price |
$20.74
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$29.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
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 |
$0.61 |
| Max. Negotiated Rate |
$14.73 |
| 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 |
$3.74
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.74
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.65
|
| 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 Medi-Cal |
$3.84
|
| 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 Medicare Advantage/Dual Product |
$5.24
|
| 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: Anthem Blue Cross of CA Exchange |
$11.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$11.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$11.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.73
|
| 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 |
$1.93
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Central Health Plan Commercial |
$3.43
|
| Rate for Payer: Central Health Plan Commercial |
$3.84
|
| Rate for Payer: Central Health Plan Commercial |
$5.59
|
| Rate for Payer: Cigna of CA HMO |
$3.00
|
| Rate for Payer: Cigna of CA HMO |
$4.89
|
| Rate for Payer: Cigna of CA HMO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$3.00
|
| Rate for Payer: Cigna of CA PPO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$4.89
|
| 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 |
$3.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.80
|
| Rate for Payer: EPIC Health Plan Senior |
$2.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1.92
|
| Rate for Payer: EPIC Health Plan Senior |
$1.72
|
| Rate for Payer: Galaxy Health WC |
$5.94
|
| Rate for Payer: Galaxy Health WC |
$4.08
|
| Rate for Payer: Galaxy Health WC |
$3.65
|
| Rate for Payer: Global Benefits Group Commercial |
$4.19
|
| Rate for Payer: Global Benefits Group Commercial |
$2.88
|
| Rate for Payer: Global Benefits Group Commercial |
$2.57
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.89
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Networks By Design Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$2.15
|
| Rate for Payer: Networks By Design Commercial |
$3.50
|
| Rate for Payer: Prime Health Services Commercial |
$5.94
|
| Rate for Payer: Prime Health Services Commercial |
$4.08
|
| Rate for Payer: Prime Health Services Commercial |
$3.65
|
| Rate for Payer: Riverside University Health System MISP |
$1.92
|
| Rate for Payer: Riverside University Health System MISP |
$2.80
|
| 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 |
$1.61
|
| 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 HMO |
$2.55
|
| Rate for Payer: United Healthcare All Other HMO |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO |
$1.57
|
| Rate for Payer: United Healthcare HMO Rider |
$1.72
|
| Rate for Payer: United Healthcare HMO Rider |
$2.50
|
| Rate for Payer: United Healthcare HMO Rider |
$1.53
|
| 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 |
$5.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.65
|
| Rate for Payer: Vantage Medical Group Senior |
$5.94
|
| Rate for Payer: Vantage Medical Group Senior |
$3.65
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
|
|
AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]
|
Facility
|
IP
|
$6.99
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$6.29 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$5.61
|
| Rate for Payer: Blue Shield of California Commercial |
$3.85
|
| Rate for Payer: Blue Shield of California Commercial |
$3.44
|
| Rate for Payer: Blue Shield of California EPN |
$2.16
|
| Rate for Payer: Blue Shield of California EPN |
$3.52
|
| Rate for Payer: Blue Shield of California EPN |
$2.42
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Central Health Plan Commercial |
$3.84
|
| Rate for Payer: Central Health Plan Commercial |
$3.43
|
| Rate for Payer: Central Health Plan Commercial |
$5.59
|
| Rate for Payer: Cigna of CA HMO |
$4.89
|
| Rate for Payer: Cigna of CA HMO |
$3.00
|
| Rate for Payer: Cigna of CA HMO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$4.89
|
| Rate for Payer: Cigna of CA PPO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$3.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1.92
|
| Rate for Payer: EPIC Health Plan Senior |
$1.72
|
| Rate for Payer: EPIC Health Plan Senior |
$2.80
|
| Rate for Payer: Galaxy Health WC |
$4.08
|
| Rate for Payer: Galaxy Health WC |
$3.65
|
| Rate for Payer: Galaxy Health WC |
$5.94
|
| Rate for Payer: Global Benefits Group Commercial |
$4.19
|
| Rate for Payer: Global Benefits Group Commercial |
$2.88
|
| Rate for Payer: Global Benefits Group Commercial |
$2.57
|
| 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: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
| Rate for Payer: Networks By Design Commercial |
$3.50
|
| Rate for Payer: Networks By Design Commercial |
$2.15
|
| 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: United Healthcare All Other Commercial |
$1.61
|
| 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 HMO |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO |
$1.57
|
| Rate for Payer: United Healthcare All Other HMO |
$2.55
|
| Rate for Payer: United Healthcare HMO Rider |
$1.53
|
| Rate for Payer: United Healthcare HMO Rider |
$1.72
|
| Rate for Payer: United Healthcare HMO Rider |
$2.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.40
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION [121291]
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$3.85
|
| Rate for Payer: Blue Shield of California Commercial |
$3.73
|
| Rate for Payer: Blue Shield of California Commercial |
$3.61
|
| Rate for Payer: Blue Shield of California EPN |
$2.27
|
| Rate for Payer: Blue Shield of California EPN |
$2.42
|
| Rate for Payer: Blue Shield of California EPN |
$2.34
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Central Health Plan Commercial |
$3.72
|
| Rate for Payer: Central Health Plan Commercial |
$3.60
|
| Rate for Payer: Central Health Plan Commercial |
$3.84
|
| Rate for Payer: Cigna of CA HMO |
$3.36
|
| Rate for Payer: Cigna of CA HMO |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$3.25
|
| Rate for Payer: Cigna of CA PPO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$3.25
|
| Rate for Payer: Cigna of CA PPO |
$3.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: EPIC Health Plan Senior |
$1.86
|
| Rate for Payer: EPIC Health Plan Senior |
$1.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1.92
|
| Rate for Payer: Galaxy Health WC |
$3.95
|
| Rate for Payer: Galaxy Health WC |
$3.83
|
| Rate for Payer: Galaxy Health WC |
$4.08
|
| Rate for Payer: Global Benefits Group Commercial |
$2.88
|
| Rate for Payer: Global Benefits Group Commercial |
$2.79
|
| Rate for Payer: Global Benefits Group Commercial |
$2.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: Multiplan Commercial |
$3.38
|
| Rate for Payer: Networks By Design Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$2.25
|
| Rate for Payer: Networks By Design Commercial |
$2.33
|
| Rate for Payer: Prime Health Services Commercial |
$3.95
|
| Rate for Payer: Prime Health Services Commercial |
$4.08
|
| Rate for Payer: Prime Health Services Commercial |
$3.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO |
$1.70
|
| Rate for Payer: United Healthcare All Other HMO |
$1.64
|
| Rate for Payer: United Healthcare All Other HMO |
$1.75
|
| Rate for Payer: United Healthcare HMO Rider |
$1.61
|
| Rate for Payer: United Healthcare HMO Rider |
$1.66
|
| Rate for Payer: United Healthcare HMO Rider |
$1.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.47
|
|
