|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 60687-783-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 59651-539-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 50742-175-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 59651-540-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 42799-959-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 50742-176-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 50742-176-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 59651-540-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 42799-959-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION [10358]
|
Facility
|
OP
|
$150.96
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.86 |
| Max. Negotiated Rate |
$113.22 |
| Rate for Payer: Adventist Health Commercial |
$30.19
|
| Rate for Payer: Adventist Health Commercial |
$58.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$80.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$155.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$200.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$103.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.64
|
| Rate for Payer: Blue Shield of California Commercial |
$92.09
|
| Rate for Payer: Blue Shield of California Commercial |
$177.75
|
| Rate for Payer: Blue Shield of California EPN |
$73.67
|
| Rate for Payer: Blue Shield of California EPN |
$142.20
|
| Rate for Payer: Cash Price |
$83.03
|
| Rate for Payer: Cash Price |
$160.27
|
| Rate for Payer: Cash Price |
$160.27
|
| Rate for Payer: Cash Price |
$83.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$134.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.64
|
| Rate for Payer: Dignity Health Senior |
$8.64
|
| Rate for Payer: Dignity Health Senior |
$8.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$186.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$7.86
|
| Rate for Payer: EPIC Health Plan Medicare |
$7.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$134.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.89
|
| Rate for Payer: Heritage Provider Network Senior |
$134.92
|
| Rate for Payer: Heritage Provider Network Senior |
$69.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$72.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$139.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.90
|
| Rate for Payer: Multiplan Commercial |
$113.22
|
| Rate for Payer: Multiplan Commercial |
$218.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$60.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$116.56
|
| Rate for Payer: TriValley Medical Group Senior |
$116.56
|
| Rate for Payer: TriValley Medical Group Senior |
$60.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$54.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$105.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$96.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$49.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.64
|
| Rate for Payer: Vantage Medical Group Senior |
$8.64
|
| Rate for Payer: Vantage Medical Group Senior |
$8.64
|
|
|
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION [10358]
|
Facility
|
IP
|
$150.96
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.32 |
| Max. Negotiated Rate |
$113.22 |
| Rate for Payer: Adventist Health Commercial |
$30.19
|
| Rate for Payer: Adventist Health Commercial |
$58.28
|
| Rate for Payer: Cash Price |
$83.03
|
| Rate for Payer: Cash Price |
$160.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$134.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$157.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$134.92
|
| Rate for Payer: Heritage Provider Network Senior |
$134.92
|
| Rate for Payer: Heritage Provider Network Senior |
$69.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.85
|
| Rate for Payer: Multiplan Commercial |
$113.22
|
| Rate for Payer: Multiplan Commercial |
$218.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$54.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$105.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$49.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$96.48
|
|
|
ISOTRETINOIN 10 MG CAPSULE [10359]
|
Facility
|
OP
|
$6.02
|
|
|
Service Code
|
NDC 0378-6611-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.51
|
| Rate for Payer: Blue Shield of California Commercial |
$3.67
|
| Rate for Payer: Blue Shield of California EPN |
$2.94
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.12
|
| Rate for Payer: Dignity Health Senior |
$5.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.73
|
| Rate for Payer: Heritage Provider Network Senior |
$3.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.21
|
| Rate for Payer: Multiplan Commercial |
$4.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.41
|
| Rate for Payer: TriValley Medical Group Senior |
$2.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.12
|
| Rate for Payer: Vantage Medical Group Senior |
$5.12
|
|
|
ISOTRETINOIN 10 MG CAPSULE [10359]
|
Facility
|
IP
|
$6.02
|
|
|
Service Code
|
NDC 0378-6611-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.08
|
| Rate for Payer: Heritage Provider Network Senior |
$4.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.51
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
|
IP
|
$7.58
|
|
|
Service Code
|
NDC 0555-1055-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$5.68 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.13
|
| Rate for Payer: Heritage Provider Network Senior |
$5.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.90
|
| Rate for Payer: Multiplan Commercial |
$5.68
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
|
OP
|
$7.14
|
|
|
Service Code
|
NDC 0378-6612-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.36
|
| Rate for Payer: Blue Shield of California Commercial |
$4.36
|
| Rate for Payer: Blue Shield of California EPN |
$3.48
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.07
|
| Rate for Payer: Dignity Health Senior |
$6.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.42
|
| Rate for Payer: Heritage Provider Network Senior |
$4.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.86
|
| Rate for Payer: TriValley Medical Group Senior |
$2.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.07
|
| Rate for Payer: Vantage Medical Group Senior |
$6.07
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
|
OP
|
$7.58
|
|
|
Service Code
|
NDC 0555-1055-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.68
|
| Rate for Payer: Blue Shield of California Commercial |
$4.62
|
| Rate for Payer: Blue Shield of California EPN |
$3.70
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.44
|
| Rate for Payer: Dignity Health Senior |
$6.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.69
|
| Rate for Payer: Heritage Provider Network Senior |
$4.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.31
|
| Rate for Payer: Multiplan Commercial |
$5.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.03
|
| Rate for Payer: TriValley Medical Group Senior |
$3.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.44
|
| Rate for Payer: Vantage Medical Group Senior |
$6.44
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
|
IP
|
$7.14
|
|
|
Service Code
|
NDC 0378-6612-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.83
|
| Rate for Payer: Heritage Provider Network Senior |
$4.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
|
|
ISOTRETINOIN 40 MG CAPSULE [10361]
|
Facility
|
OP
|
$8.30
|
|
|
Service Code
|
NDC 0378-6614-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$7.05 |
| Rate for Payer: Adventist Health Commercial |
$1.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.22
|
| Rate for Payer: Blue Shield of California Commercial |
$5.06
|
| Rate for Payer: Blue Shield of California EPN |
$4.05
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.05
|
| Rate for Payer: Dignity Health Senior |
$7.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.14
|
| Rate for Payer: Heritage Provider Network Senior |
$5.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.81
|
| Rate for Payer: Multiplan Commercial |
$6.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.32
|
| Rate for Payer: TriValley Medical Group Senior |
$3.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.05
|
| Rate for Payer: Vantage Medical Group Senior |
$7.05
|
|
|
ISOTRETINOIN 40 MG CAPSULE [10361]
|
Facility
|
IP
|
$8.30
|
|
|
Service Code
|
NDC 0378-6614-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$6.22 |
| Rate for Payer: Adventist Health Commercial |
$1.66
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.62
|
| Rate for Payer: Heritage Provider Network Senior |
$5.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.08
|
| Rate for Payer: Multiplan Commercial |
$6.22
|
|
|
ISRADIPINE 2.5 MG CAPSULE [10362]
|
Facility
|
IP
|
$1.73
|
|
|
Service Code
|
NDC 16252-539-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.17
|
| Rate for Payer: Heritage Provider Network Senior |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
|
|
ISRADIPINE 2.5 MG CAPSULE [10362]
|
Facility
|
OP
|
$1.73
|
|
|
Service Code
|
NDC 16252-539-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.84
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.47
|
| Rate for Payer: Dignity Health Senior |
$1.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.07
|
| Rate for Payer: Heritage Provider Network Senior |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.69
|
| Rate for Payer: TriValley Medical Group Senior |
$0.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.47
|
| Rate for Payer: Vantage Medical Group Senior |
$1.47
|
|
|
ISRADIPINE ORAL SUSPENSION COMPOUND 1 MG/ML [4080283]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 9994-0802-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| 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 Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
ISRADIPINE ORAL SUSPENSION COMPOUND 1 MG/ML [4080283]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 9994-0802-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 49884-239-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
OP
|
$34.45
|
|
|
Service Code
|
NDC 50458-290-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$29.28 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.84
|
| Rate for Payer: Blue Shield of California Commercial |
$21.01
|
| Rate for Payer: Blue Shield of California EPN |
$16.81
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.28
|
| Rate for Payer: Dignity Health Senior |
$29.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.32
|
| Rate for Payer: Heritage Provider Network Senior |
$21.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.11
|
| Rate for Payer: Multiplan Commercial |
$25.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.78
|
| Rate for Payer: TriValley Medical Group Senior |
$13.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.28
|
| Rate for Payer: Vantage Medical Group Senior |
$29.28
|
|
