|
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET [34712]
|
Facility
OP
|
$4.20
|
|
|
Service Code
|
CPT J0571
|
| Hospital Charge Code |
ERX34712
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Senior |
$3.57
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
OP
|
$0.44
|
|
|
Service Code
|
NDC 23155-192-01
|
| Hospital Charge Code |
1711391
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
OP
|
$2.12
|
|
|
Service Code
|
NDC 50268-143-15
|
| Hospital Charge Code |
1711391
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.59
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.80
|
| Rate for Payer: Dignity Health Senior |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1.80
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
IP
|
$0.44
|
|
|
Service Code
|
NDC 23155-192-01
|
| Hospital Charge Code |
1711391
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
IP
|
$2.12
|
|
|
Service Code
|
NDC 50268-143-15
|
| Hospital Charge Code |
1711391
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
OP
|
$0.80
|
|
|
Service Code
|
NDC 68001-309-00
|
| Hospital Charge Code |
1711391
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Senior |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
IP
|
$0.80
|
|
|
Service Code
|
NDC 68001-309-00
|
| Hospital Charge Code |
1711391
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
OP
|
$0.86
|
|
|
Service Code
|
NDC 60505-0157-1
|
| Hospital Charge Code |
1711391
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Senior |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
OP
|
$2.12
|
|
|
Service Code
|
NDC 50268-143-11
|
| Hospital Charge Code |
1711391
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.59
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.80
|
| Rate for Payer: Dignity Health Senior |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1.80
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
IP
|
$2.12
|
|
|
Service Code
|
NDC 50268-143-11
|
| Hospital Charge Code |
1711391
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
IP
|
$0.86
|
|
|
Service Code
|
NDC 60505-0157-1
|
| Hospital Charge Code |
1711391
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
BUPROPION HCL 75 MG TABLET [9322]
|
Facility
OP
|
$0.60
|
|
|
Service Code
|
NDC 68001-308-00
|
| Hospital Charge Code |
1711474
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Senior |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
BUPROPION HCL 75 MG TABLET [9322]
|
Facility
IP
|
$0.60
|
|
|
Service Code
|
NDC 68001-308-00
|
| Hospital Charge Code |
1711474
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
BUPROPION HCL 75 MG TABLET [9322]
|
Facility
OP
|
$0.64
|
|
|
Service Code
|
NDC 60505-0158-1
|
| Hospital Charge Code |
1711474
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
BUPROPION HCL 75 MG TABLET [9322]
|
Facility
IP
|
$0.64
|
|
|
Service Code
|
NDC 60505-0158-1
|
| Hospital Charge Code |
1711474
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
|
BUPROPION HCL 75 MG TABLET [9322]
|
Facility
OP
|
$0.34
|
|
|
Service Code
|
NDC 23155-191-01
|
| Hospital Charge Code |
1711474
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
BUPROPION HCL 75 MG TABLET [9322]
|
Facility
IP
|
$0.34
|
|
|
Service Code
|
NDC 23155-191-01
|
| Hospital Charge Code |
1711474
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
OP
|
$0.96
|
|
|
Service Code
|
NDC 68084-697-11
|
| Hospital Charge Code |
1711719
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: Dignity Health Senior |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Senior |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
OP
|
$0.96
|
|
|
Service Code
|
NDC 68084-697-01
|
| Hospital Charge Code |
1711719
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: Dignity Health Senior |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Senior |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
OP
|
$0.28
|
|
|
Service Code
|
NDC 42806-410-60
|
| Hospital Charge Code |
1711719
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
IP
|
$0.96
|
|
|
Service Code
|
NDC 68084-697-01
|
| Hospital Charge Code |
1711719
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.66
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Senior |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
IP
|
$0.30
|
|
|
Service Code
|
NDC 0591-3540-60
|
| Hospital Charge Code |
1711719
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
IP
|
$0.28
|
|
|
Service Code
|
NDC 42806-410-60
|
| Hospital Charge Code |
1711719
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
IP
|
$0.96
|
|
|
Service Code
|
NDC 68084-697-11
|
| Hospital Charge Code |
1711719
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.66
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Senior |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
OP
|
$0.30
|
|
|
Service Code
|
NDC 0591-3540-60
|
| Hospital Charge Code |
1711719
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
