|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
OP
|
$1.80
|
|
|
Service Code
|
NDC 50268-140-13
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.99
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.06
|
| Rate for Payer: BCBS Transplant Transplant |
$1.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.88
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Central Health Plan Commercial |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.62
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.35
|
| Rate for Payer: IEHP medi-cal |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: Riverside University Health MISP |
$0.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare HMO Rider |
$0.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
IP
|
$1.80
|
|
|
Service Code
|
NDC 50268-140-13
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.96
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Central Health Plan Commercial |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
OP
|
$1.80
|
|
|
Service Code
|
NDC 50268-140-11
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.99
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.06
|
| Rate for Payer: BCBS Transplant Transplant |
$1.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.88
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Central Health Plan Commercial |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.62
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.35
|
| Rate for Payer: IEHP medi-cal |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: Riverside University Health MISP |
$0.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare HMO Rider |
$0.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
IP
|
$0.22
|
|
|
Service Code
|
NDC 16729-443-10
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
OP
|
$0.22
|
|
|
Service Code
|
NDC 16729-443-10
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.17
|
| Rate for Payer: IEHP medi-cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: Riverside University Health MISP |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
IP
|
$1.58
|
|
|
Service Code
|
NDC 0904-7084-04
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.84
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Central Health Plan Commercial |
$1.26
|
| Rate for Payer: Cigna of CA HMO |
$1.11
|
| Rate for Payer: Cigna of CA PPO |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Networks By Design Commercial |
$1.03
|
| Rate for Payer: Prime Health Services Commercial |
$1.34
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
OP
|
$0.20
|
|
|
Service Code
|
NDC 64679-102-01
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: BCBS Transplant Transplant |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.15
|
| Rate for Payer: IEHP medi-cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: Riverside University Health MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
OP
|
$1.58
|
|
|
Service Code
|
NDC 0904-7084-04
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.87
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.93
|
| Rate for Payer: BCBS Transplant Transplant |
$0.95
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Central Health Plan Commercial |
$1.26
|
| Rate for Payer: Cigna of CA HMO |
$1.11
|
| Rate for Payer: Cigna of CA PPO |
$1.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.42
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.18
|
| Rate for Payer: IEHP medi-cal |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Networks By Design Commercial |
$1.03
|
| Rate for Payer: Prime Health Services Commercial |
$1.34
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.95
|
| Rate for Payer: Riverside University Health MISP |
$0.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.79
|
| Rate for Payer: United Healthcare All Other HMO |
$0.79
|
| Rate for Payer: United Healthcare HMO Rider |
$0.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: Vantage Medical Group Senior |
$1.34
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
IP
|
$0.22
|
|
|
Service Code
|
NDC 68180-319-06
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
OP
|
$0.22
|
|
|
Service Code
|
NDC 68180-319-06
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.17
|
| Rate for Payer: IEHP medi-cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: Riverside University Health MISP |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
IP
|
$0.22
|
|
|
Service Code
|
NDC 68180-319-09
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
OP
|
$0.22
|
|
|
Service Code
|
NDC 68180-319-09
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.17
|
| Rate for Payer: IEHP medi-cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: Riverside University Health MISP |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
OP
|
$0.27
|
|
|
Service Code
|
NDC 16729-444-10
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: BCBS Transplant Transplant |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.20
|
| Rate for Payer: IEHP medi-cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: Riverside University Health MISP |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
IP
|
$3.04
|
|
|
Service Code
|
NDC 68084-252-21
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.62
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Central Health Plan Commercial |
$2.43
|
| Rate for Payer: Cigna of CA HMO |
$2.13
|
| Rate for Payer: Cigna of CA PPO |
$2.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.58
|
| Rate for Payer: Global Benefits Group Commercial |
$1.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
| Rate for Payer: Networks By Design Commercial |
$1.98
|
| Rate for Payer: Prime Health Services Commercial |
$2.58
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
OP
|
$3.04
|
|
|
Service Code
|
NDC 68084-252-11
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.67
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.80
|
| Rate for Payer: BCBS Transplant Transplant |
$1.82
|
| Rate for Payer: Blue Shield of California Commercial |
$1.91
|
| Rate for Payer: Blue Shield of California EPN |
$1.49
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Central Health Plan Commercial |
$2.43
|
| Rate for Payer: Cigna of CA HMO |
$2.13
|
| Rate for Payer: Cigna of CA PPO |
$2.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.58
|
| Rate for Payer: Global Benefits Group Commercial |
$1.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.74
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.28
|
| Rate for Payer: IEHP medi-cal |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
| Rate for Payer: Networks By Design Commercial |
$1.98
|
| Rate for Payer: Prime Health Services Commercial |
$2.58
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.82
|
| Rate for Payer: Riverside University Health MISP |
$1.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.52
|
| Rate for Payer: United Healthcare All Other HMO |
$1.52
|
| Rate for Payer: United Healthcare HMO Rider |
$1.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.58
|
| Rate for Payer: Vantage Medical Group Senior |
$2.58
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
OP
|
$0.94
|
|
|
Service Code
|
NDC 68001-321-04
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.56
|
| Rate for Payer: BCBS Transplant Transplant |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.75
|
| Rate for Payer: Cigna of CA HMO |
$0.66
|
| Rate for Payer: Cigna of CA PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.80
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.85
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.71
|
| Rate for Payer: IEHP medi-cal |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Prime Health Services Commercial |
$0.80
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: Riverside University Health MISP |
$0.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
IP
|
$0.94
|
|
|
Service Code
|
NDC 68001-321-04
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.75
|
| Rate for Payer: Cigna of CA HMO |
$0.66
|
| Rate for Payer: Cigna of CA PPO |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.80
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Prime Health Services Commercial |
$0.80
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
OP
|
$0.48
|
|
|
Service Code
|
NDC 63304-724-30
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: BCBS Transplant Transplant |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.36
|
| Rate for Payer: IEHP medi-cal |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: Riverside University Health MISP |
$0.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
IP
|
$0.48
|
|
|
Service Code
|
NDC 63304-724-30
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
OP
|
$3.04
|
|
|
Service Code
|
NDC 68084-252-21
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.67
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.80
|
| Rate for Payer: BCBS Transplant Transplant |
$1.82
|
| Rate for Payer: Blue Shield of California Commercial |
$1.91
|
| Rate for Payer: Blue Shield of California EPN |
$1.49
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Central Health Plan Commercial |
$2.43
|
| Rate for Payer: Cigna of CA HMO |
$2.13
|
| Rate for Payer: Cigna of CA PPO |
$2.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.58
|
| Rate for Payer: Global Benefits Group Commercial |
$1.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.74
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.28
|
| Rate for Payer: IEHP medi-cal |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
| Rate for Payer: Networks By Design Commercial |
$1.98
|
| Rate for Payer: Prime Health Services Commercial |
$2.58
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.82
|
| Rate for Payer: Riverside University Health MISP |
$1.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.52
|
| Rate for Payer: United Healthcare All Other HMO |
$1.52
|
| Rate for Payer: United Healthcare HMO Rider |
$1.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.58
|
| Rate for Payer: Vantage Medical Group Senior |
$2.58
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
IP
|
$0.27
|
|
|
Service Code
|
NDC 16729-444-10
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
IP
|
$3.04
|
|
|
Service Code
|
NDC 68084-252-11
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.62
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Central Health Plan Commercial |
$2.43
|
| Rate for Payer: Cigna of CA HMO |
$2.13
|
| Rate for Payer: Cigna of CA PPO |
$2.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.58
|
| Rate for Payer: Global Benefits Group Commercial |
$1.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
| Rate for Payer: Networks By Design Commercial |
$1.98
|
| Rate for Payer: Prime Health Services Commercial |
$2.58
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS
|
Facility
IP
|
$100,546.29
|
|
|
Service Code
|
APR-DRG 8424
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$100,546.29 |
| Rate for Payer: Adventist Health Medi-Cal |
$84,374.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$100,546.29
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS
|
Facility
IP
|
$41,464.38
|
|
|
Service Code
|
APR-DRG 8423
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$41,464.38 |
| Rate for Payer: Adventist Health Medi-Cal |
$34,795.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$41,464.38
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 8421
|
| Min. Negotiated Rate |
$11,891.89 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,891.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$14,171.17
|
|
