|
BELATACEPT 250 MG INTRAVENOUS SOLUTION [153042]
|
Facility
|
OP
|
$1,163.86
|
|
|
Service Code
|
HCPCS J0485
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$1,047.47 |
| Rate for Payer: Adventist Health Commercial |
$232.77
|
| Rate for Payer: Adventist Health Medi-Cal |
$3.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$24.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.28
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.12
|
| Rate for Payer: Blue Shield of California Commercial |
$5.13
|
| Rate for Payer: Blue Shield of California EPN |
$4.66
|
| Rate for Payer: Cash Price |
$523.74
|
| Rate for Payer: Cash Price |
$523.74
|
| Rate for Payer: Central Health Plan Commercial |
$931.09
|
| Rate for Payer: Cigna of CA HMO |
$814.70
|
| Rate for Payer: Cigna of CA PPO |
$814.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$814.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.42
|
| Rate for Payer: EPIC Health Plan Senior |
$4.28
|
| Rate for Payer: Galaxy Health WC |
$989.28
|
| Rate for Payer: Global Benefits Group Commercial |
$698.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,047.47
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$739.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$232.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.21
|
| Rate for Payer: Multiplan Commercial |
$872.89
|
| Rate for Payer: Networks By Design Commercial |
$581.93
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$3.89
|
| Rate for Payer: Prime Health Services Commercial |
$989.28
|
| Rate for Payer: Prime Health Services Medicare |
$4.12
|
| Rate for Payer: Riverside University Health System MISP |
$4.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$698.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$698.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$436.80
|
| Rate for Payer: United Healthcare All Other HMO |
$425.16
|
| Rate for Payer: United Healthcare HMO Rider |
$415.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$381.16
|
| Rate for Payer: Upland Medical Group Pediatric |
$3.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.28
|
| Rate for Payer: Vantage Medical Group Senior |
$4.28
|
|
|
BELIMUMAB 120 MG INTRAVENOUS SOLUTION [108842]
|
Facility
|
OP
|
$808.33
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.30 |
| Max. Negotiated Rate |
$727.50 |
| Rate for Payer: Adventist Health Commercial |
$161.67
|
| Rate for Payer: Adventist Health Medi-Cal |
$58.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$340.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$72.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$64.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$73.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$91.24
|
| Rate for Payer: Blue Shield of California Commercial |
$68.45
|
| Rate for Payer: Blue Shield of California EPN |
$62.23
|
| Rate for Payer: Cash Price |
$363.75
|
| Rate for Payer: Cash Price |
$363.75
|
| Rate for Payer: Central Health Plan Commercial |
$646.66
|
| Rate for Payer: Cigna of CA HMO |
$565.83
|
| Rate for Payer: Cigna of CA PPO |
$565.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$64.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$64.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$565.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.19
|
| Rate for Payer: EPIC Health Plan Senior |
$64.13
|
| Rate for Payer: Galaxy Health WC |
$687.08
|
| Rate for Payer: Global Benefits Group Commercial |
$485.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$727.50
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$95.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$58.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$58.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$513.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$117.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$81.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$161.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$78.12
|
| Rate for Payer: Multiplan Commercial |
$606.25
|
| Rate for Payer: Networks By Design Commercial |
$404.17
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$58.30
|
| Rate for Payer: Prime Health Services Commercial |
$687.08
|
| Rate for Payer: Prime Health Services Medicare |
$61.80
|
| Rate for Payer: Riverside University Health System MISP |
$64.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$485.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$485.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$303.37
|
| Rate for Payer: United Healthcare All Other HMO |
$295.28
|
| Rate for Payer: United Healthcare HMO Rider |
$288.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$264.73
|
| Rate for Payer: Upland Medical Group Pediatric |
$58.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$64.13
|
| Rate for Payer: Vantage Medical Group Senior |
$64.13
|
|
|
BELIMUMAB 120 MG INTRAVENOUS SOLUTION [108842]
|
Facility
|
IP
|
$808.33
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.67 |
| Max. Negotiated Rate |
$727.50 |
| Rate for Payer: Adventist Health Commercial |
$161.67
|
| Rate for Payer: Blue Shield of California Commercial |
$648.28
|
| Rate for Payer: Blue Shield of California EPN |
$407.40
|
| Rate for Payer: Cash Price |
$363.75
|
| Rate for Payer: Central Health Plan Commercial |
$646.66
|
| Rate for Payer: Cigna of CA HMO |
$565.83
|
| Rate for Payer: Cigna of CA PPO |
$565.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$565.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$323.33
|
| Rate for Payer: EPIC Health Plan Senior |
$323.33
|
| Rate for Payer: Galaxy Health WC |
$687.08
|
| Rate for Payer: Global Benefits Group Commercial |
$485.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$727.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$513.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$476.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$161.67
|
| Rate for Payer: Multiplan Commercial |
$606.25
|
| Rate for Payer: Networks By Design Commercial |
$404.17
|
| Rate for Payer: Prime Health Services Commercial |
$687.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$303.37
|
| Rate for Payer: United Healthcare All Other HMO |
$295.28
|
| Rate for Payer: United Healthcare HMO Rider |
$288.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$264.73
|
|
|
BELIMUMAB 400 MG INTRAVENOUS SOLUTION [108843]
|
Facility
|
IP
|
$2,694.23
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$538.85 |
| Max. Negotiated Rate |
$2,424.81 |
| Rate for Payer: Adventist Health Commercial |
$538.85
|
| Rate for Payer: Blue Shield of California Commercial |
$2,160.77
|
| Rate for Payer: Blue Shield of California EPN |
$1,357.89
|
| Rate for Payer: Cash Price |
$1,212.40
|
| Rate for Payer: Central Health Plan Commercial |
$2,155.38
|
| Rate for Payer: Cigna of CA HMO |
$1,885.96
|
| Rate for Payer: Cigna of CA PPO |
$1,885.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,885.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,077.69
|
| Rate for Payer: EPIC Health Plan Senior |
$1,077.69
|
| Rate for Payer: Galaxy Health WC |
$2,290.10
|
| Rate for Payer: Global Benefits Group Commercial |
$1,616.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,424.81
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,710.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,589.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$538.85
|
| Rate for Payer: Multiplan Commercial |
$2,020.67
|
| Rate for Payer: Networks By Design Commercial |
$1,347.12
|
| Rate for Payer: Prime Health Services Commercial |
$2,290.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,011.14
|
| Rate for Payer: United Healthcare All Other HMO |
$984.20
|
| Rate for Payer: United Healthcare HMO Rider |
$962.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$882.36
|
|
|
BELIMUMAB 400 MG INTRAVENOUS SOLUTION [108843]
|
Facility
|
OP
|
$2,694.23
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.30 |
| Max. Negotiated Rate |
$2,424.81 |
| Rate for Payer: Adventist Health Commercial |
$538.85
|
| Rate for Payer: Adventist Health Medi-Cal |
$58.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$340.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$72.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$64.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$73.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$91.24
|
| Rate for Payer: Blue Shield of California Commercial |
$68.45
|
| Rate for Payer: Blue Shield of California EPN |
$62.23
|
| Rate for Payer: Cash Price |
$1,212.40
|
| Rate for Payer: Cash Price |
$1,212.40
|
| Rate for Payer: Central Health Plan Commercial |
$2,155.38
|
| Rate for Payer: Cigna of CA HMO |
$1,885.96
|
| Rate for Payer: Cigna of CA PPO |
$1,885.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$64.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$64.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,885.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.19
|
| Rate for Payer: EPIC Health Plan Senior |
$64.13
|
| Rate for Payer: Galaxy Health WC |
$2,290.10
|
| Rate for Payer: Global Benefits Group Commercial |
$1,616.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,424.81
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$95.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$58.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$58.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,710.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$117.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$81.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$538.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$78.12
|
| Rate for Payer: Multiplan Commercial |
$2,020.67
|
| Rate for Payer: Networks By Design Commercial |
$1,347.12
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$58.30
|
| Rate for Payer: Prime Health Services Commercial |
$2,290.10
|
| Rate for Payer: Prime Health Services Medicare |
$61.80
|
| Rate for Payer: Riverside University Health System MISP |
$64.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,616.54
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,616.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,011.14
|
| Rate for Payer: United Healthcare All Other HMO |
$984.20
|
| Rate for Payer: United Healthcare HMO Rider |
$962.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$882.36
|
| Rate for Payer: Upland Medical Group Pediatric |
$58.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$64.13
|
| Rate for Payer: Vantage Medical Group Senior |
$64.13
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
|
IP
|
$26.42
|
|
|
Service Code
|
NDC 0574704512
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.28 |
| Max. Negotiated Rate |
$23.78 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Blue Shield of California Commercial |
$21.19
|
| Rate for Payer: Blue Shield of California EPN |
$13.32
|
| Rate for Payer: Cash Price |
$11.89
|
| Rate for Payer: Central Health Plan Commercial |
$21.14
|
| Rate for Payer: Cigna of CA HMO |
$18.49
|
| Rate for Payer: Cigna of CA PPO |
$18.49
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.57
|
| Rate for Payer: EPIC Health Plan Senior |
$10.57
|
| Rate for Payer: Galaxy Health WC |
$22.46
|
| Rate for Payer: Global Benefits Group Commercial |
$15.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$23.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$16.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.28
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
| Rate for Payer: Networks By Design Commercial |
$17.17
|
| Rate for Payer: Prime Health Services Commercial |
$22.46
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
|
OP
|
$26.42
|
|
|
Service Code
|
NDC 0574704512
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.28 |
| Max. Negotiated Rate |
$23.78 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.82
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$12.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.37
|
| Rate for Payer: Blue Shield of California Commercial |
$16.75
|
| Rate for Payer: Blue Shield of California EPN |
$10.54
|
| Rate for Payer: Cash Price |
$11.89
|
| Rate for Payer: Central Health Plan Commercial |
$21.14
|
| Rate for Payer: Cigna of CA HMO |
$18.49
|
| Rate for Payer: Cigna of CA PPO |
$18.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$22.46
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.57
|
| Rate for Payer: EPIC Health Plan Senior |
$10.57
|
| Rate for Payer: Galaxy Health WC |
$22.46
|
| Rate for Payer: Global Benefits Group Commercial |
$15.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$23.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$16.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18.49
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
| Rate for Payer: Networks By Design Commercial |
$17.17
|
| Rate for Payer: Prime Health Services Commercial |
$22.46
|
| Rate for Payer: Riverside University Health System MISP |
$10.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.21
|
| Rate for Payer: United Healthcare All Other HMO |
$13.21
|
| Rate for Payer: United Healthcare HMO Rider |
$13.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.46
|
| Rate for Payer: Vantage Medical Group Senior |
$22.46
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
|
OP
|
$26.42
|
|
|
Service Code
|
NDC 0574704501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.28 |
| Max. Negotiated Rate |
$23.78 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.82
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$12.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.37
|
| Rate for Payer: Blue Shield of California Commercial |
$16.75
|
| Rate for Payer: Blue Shield of California EPN |
$10.54
|
| Rate for Payer: Cash Price |
$11.89
|
| Rate for Payer: Central Health Plan Commercial |
$21.14
|
| Rate for Payer: Cigna of CA HMO |
$18.49
|
| Rate for Payer: Cigna of CA PPO |
$18.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$22.46
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.57
|
| Rate for Payer: EPIC Health Plan Senior |
$10.57
|
| Rate for Payer: Galaxy Health WC |
$22.46
|
| Rate for Payer: Global Benefits Group Commercial |
$15.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$23.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$16.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18.49
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
| Rate for Payer: Networks By Design Commercial |
$17.17
|
| Rate for Payer: Prime Health Services Commercial |
$22.46
|
| Rate for Payer: Riverside University Health System MISP |
$10.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.21
|
| Rate for Payer: United Healthcare All Other HMO |
$13.21
|
| Rate for Payer: United Healthcare HMO Rider |
$13.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.46
|
| Rate for Payer: Vantage Medical Group Senior |
$22.46
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
|
IP
|
$26.42
|
|
|
Service Code
|
NDC 0574704501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.28 |
| Max. Negotiated Rate |
$23.78 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Blue Shield of California Commercial |
$21.19
|
| Rate for Payer: Blue Shield of California EPN |
$13.32
|
| Rate for Payer: Cash Price |
$11.89
|
| Rate for Payer: Central Health Plan Commercial |
$21.14
|
| Rate for Payer: Cigna of CA HMO |
$18.49
|
| Rate for Payer: Cigna of CA PPO |
$18.49
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.57
|
| Rate for Payer: EPIC Health Plan Senior |
$10.57
|
| Rate for Payer: Galaxy Health WC |
$22.46
|
| Rate for Payer: Global Benefits Group Commercial |
$15.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$23.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$16.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.28
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
| Rate for Payer: Networks By Design Commercial |
$17.17
|
| Rate for Payer: Prime Health Services Commercial |
$22.46
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
|
IP
|
$32.11
|
|
|
Service Code
|
NDC 0574704012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$28.90 |
| Rate for Payer: Adventist Health Commercial |
$6.42
|
| Rate for Payer: Blue Shield of California Commercial |
$25.75
|
| Rate for Payer: Blue Shield of California EPN |
$16.18
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: Central Health Plan Commercial |
$25.69
|
| Rate for Payer: Cigna of CA HMO |
$22.48
|
| Rate for Payer: Cigna of CA PPO |
$22.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$22.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.84
|
| Rate for Payer: EPIC Health Plan Senior |
$12.84
|
| Rate for Payer: Galaxy Health WC |
$27.29
|
| Rate for Payer: Global Benefits Group Commercial |
$19.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$28.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$20.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.42
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
| Rate for Payer: Networks By Design Commercial |
$20.87
|
| Rate for Payer: Prime Health Services Commercial |
$27.29
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
|
OP
|
$32.11
|
|
|
Service Code
|
NDC 0574704012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$28.90 |
| Rate for Payer: Adventist Health Commercial |
$6.42
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$15.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.68
|
| Rate for Payer: Blue Shield of California Commercial |
$20.36
|
| Rate for Payer: Blue Shield of California EPN |
$12.81
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: Central Health Plan Commercial |
$25.69
|
| Rate for Payer: Cigna of CA HMO |
$22.48
|
| Rate for Payer: Cigna of CA PPO |
$22.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$27.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$22.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.84
|
| Rate for Payer: EPIC Health Plan Senior |
$12.84
|
| Rate for Payer: Galaxy Health WC |
$27.29
|
| Rate for Payer: Global Benefits Group Commercial |
$19.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$28.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$20.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.48
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
| Rate for Payer: Networks By Design Commercial |
$20.87
|
| Rate for Payer: Prime Health Services Commercial |
$27.29
|
| Rate for Payer: Riverside University Health System MISP |
$12.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$19.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$19.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.05
|
| Rate for Payer: United Healthcare All Other HMO |
$16.05
|
| Rate for Payer: United Healthcare HMO Rider |
$16.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.29
|
| Rate for Payer: Vantage Medical Group Senior |
$27.29
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
|
IP
|
$32.11
|
|
|
Service Code
|
NDC 0574704001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$28.90 |
| Rate for Payer: Adventist Health Commercial |
$6.42
|
| Rate for Payer: Blue Shield of California Commercial |
$25.75
|
| Rate for Payer: Blue Shield of California EPN |
$16.18
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: Central Health Plan Commercial |
$25.69
|
| Rate for Payer: Cigna of CA HMO |
$22.48
|
| Rate for Payer: Cigna of CA PPO |
$22.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$22.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.84
|
| Rate for Payer: EPIC Health Plan Senior |
$12.84
|
| Rate for Payer: Galaxy Health WC |
$27.29
|
| Rate for Payer: Global Benefits Group Commercial |
$19.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$28.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$20.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.42
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
| Rate for Payer: Networks By Design Commercial |
$20.87
|
| Rate for Payer: Prime Health Services Commercial |
$27.29
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
|
OP
|
$32.11
|
|
|
Service Code
|
NDC 0574704001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$28.90 |
| Rate for Payer: Adventist Health Commercial |
$6.42
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$15.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.68
|
| Rate for Payer: Blue Shield of California Commercial |
$20.36
|
| Rate for Payer: Blue Shield of California EPN |
$12.81
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: Central Health Plan Commercial |
$25.69
|
| Rate for Payer: Cigna of CA HMO |
$22.48
|
| Rate for Payer: Cigna of CA PPO |
$22.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$27.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$22.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.84
|
| Rate for Payer: EPIC Health Plan Senior |
$12.84
|
| Rate for Payer: Galaxy Health WC |
$27.29
|
| Rate for Payer: Global Benefits Group Commercial |
$19.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$28.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$20.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.48
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
| Rate for Payer: Networks By Design Commercial |
$20.87
|
| Rate for Payer: Prime Health Services Commercial |
$27.29
|
| Rate for Payer: Riverside University Health System MISP |
$12.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$19.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$19.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.05
|
| Rate for Payer: United Healthcare All Other HMO |
$16.05
|
| Rate for Payer: United Healthcare HMO Rider |
$16.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.29
|
| Rate for Payer: Vantage Medical Group Senior |
$27.29
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 5026811011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Central Health Plan Commercial |
$0.66
|
| Rate for Payer: Cigna of CA HMO |
$0.57
|
| Rate for Payer: Cigna of CA PPO |
$0.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Senior |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.70
|
| Rate for Payer: Global Benefits Group Commercial |
$0.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.70
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 5026811015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Central Health Plan Commercial |
$0.66
|
| Rate for Payer: Cigna of CA HMO |
$0.57
|
| Rate for Payer: Cigna of CA PPO |
$0.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Senior |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.70
|
| Rate for Payer: Global Benefits Group Commercial |
$0.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.70
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 6586211601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 6516275210
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 4354733610
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 4354733610
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
| Rate for Payer: Riverside University Health System MISP |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 5026811015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Central Health Plan Commercial |
$0.66
|
| Rate for Payer: Cigna of CA HMO |
$0.57
|
| Rate for Payer: Cigna of CA PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Senior |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.70
|
| Rate for Payer: Global Benefits Group Commercial |
$0.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.70
|
| Rate for Payer: Riverside University Health System MISP |
$0.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.41
|
| Rate for Payer: United Healthcare All Other HMO |
$0.41
|
| Rate for Payer: United Healthcare HMO Rider |
$0.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Vantage Medical Group Senior |
$0.70
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 6586211601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 5026811011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Central Health Plan Commercial |
$0.66
|
| Rate for Payer: Cigna of CA HMO |
$0.57
|
| Rate for Payer: Cigna of CA PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Senior |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.70
|
| Rate for Payer: Global Benefits Group Commercial |
$0.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.70
|
| Rate for Payer: Riverside University Health System MISP |
$0.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.41
|
| Rate for Payer: United Healthcare All Other HMO |
$0.41
|
| Rate for Payer: United Healthcare HMO Rider |
$0.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Vantage Medical Group Senior |
$0.70
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 6516275210
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
NDC 5026811115
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Central Health Plan Commercial |
$0.69
|
| Rate for Payer: Cigna of CA HMO |
$0.60
|
| Rate for Payer: Cigna of CA PPO |
$0.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.73
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Senior |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.73
|
| Rate for Payer: Global Benefits Group Commercial |
$0.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Networks By Design Commercial |
$0.56
|
| Rate for Payer: Prime Health Services Commercial |
$0.73
|
| Rate for Payer: Riverside University Health System MISP |
$0.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.43
|
| Rate for Payer: United Healthcare All Other HMO |
$0.43
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 6516275310
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
