|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 67877-454-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.95
|
| 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: Molina Healthcare of CA Medi-Cal |
$1.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 65162-630-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.95
|
| 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: Molina Healthcare of CA Medi-Cal |
$1.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
IP
|
$34.45
|
|
|
Service Code
|
NDC 50458-290-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$25.84 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.32
|
| Rate for Payer: Heritage Provider Network Senior |
$23.32
|
| 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: Multiplan Commercial |
$25.84
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 65162-630-03
|
| 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
|
|
|
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 10 MG/ML ORAL SOLUTION [19928]
|
Facility
|
IP
|
$2.35
|
|
|
Service Code
|
NDC 65162-087-74
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.59
|
| Rate for Payer: Heritage Provider Network Senior |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
|
|
ITRACONAZOLE 10 MG/ML ORAL SOLUTION [19928]
|
Facility
|
OP
|
$2.35
|
|
|
Service Code
|
NDC 65162-087-74
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.15
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.00
|
| Rate for Payer: Dignity Health Senior |
$2.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.65
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.00
|
| Rate for Payer: Vantage Medical Group Senior |
$2.00
|
|
|
ITRACONAZOLE 10 MG/ML ORAL SOLUTION [19928]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 31722-006-31
|
| 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 10 MG/ML ORAL SOLUTION [19928]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 31722-006-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.95
|
| 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: Molina Healthcare of CA Medi-Cal |
$1.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
IVABRADINE 2.5 MG PARTIAL TABLET [4082315]
|
Facility
|
IP
|
$6.26
|
|
|
Service Code
|
NDC 9994-0823-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$4.70 |
| Rate for Payer: Adventist Health Commercial |
$1.25
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.24
|
| Rate for Payer: Heritage Provider Network Senior |
$4.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$4.70
|
|
|
IVABRADINE 2.5 MG PARTIAL TABLET [4082315]
|
Facility
|
OP
|
$6.26
|
|
|
Service Code
|
NDC 9994-0823-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Adventist Health Commercial |
$1.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.70
|
| Rate for Payer: Blue Shield of California Commercial |
$3.82
|
| Rate for Payer: Blue Shield of California EPN |
$3.05
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.32
|
| Rate for Payer: Dignity Health Senior |
$5.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Senior |
$3.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$4.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.50
|
| Rate for Payer: TriValley Medical Group Senior |
$2.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.32
|
| Rate for Payer: Vantage Medical Group Senior |
$5.32
|
|
|
IVABRADINE 5 MG TABLET [204605]
|
Facility
|
OP
|
$2.70
|
|
|
Service Code
|
NDC 62332-679-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1.65
|
| Rate for Payer: Blue Shield of California EPN |
$1.32
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.29
|
| Rate for Payer: Dignity Health Senior |
$2.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.89
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.29
|
| Rate for Payer: Vantage Medical Group Senior |
$2.29
|
|
|
IVABRADINE 5 MG TABLET [204605]
|
Facility
|
OP
|
$12.65
|
|
|
Service Code
|
NDC 60687-862-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$10.75 |
| Rate for Payer: Adventist Health Commercial |
$2.53
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.49
|
| Rate for Payer: Blue Shield of California Commercial |
$7.72
|
| Rate for Payer: Blue Shield of California EPN |
$6.17
|
| Rate for Payer: Cash Price |
$6.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.75
|
| Rate for Payer: Dignity Health Senior |
$10.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.83
|
| Rate for Payer: Heritage Provider Network Senior |
$7.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.86
|
| Rate for Payer: Multiplan Commercial |
$9.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.06
|
| Rate for Payer: TriValley Medical Group Senior |
$5.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.75
|
| Rate for Payer: Vantage Medical Group Senior |
$10.75
|
|
|
IVABRADINE 5 MG TABLET [204605]
|
Facility
|
IP
|
$12.65
|
|
|
Service Code
|
NDC 60687-862-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$9.49 |
| Rate for Payer: Adventist Health Commercial |
$2.53
|
| Rate for Payer: Cash Price |
$6.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.56
|
| Rate for Payer: Heritage Provider Network Senior |
$8.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.16
|
| Rate for Payer: Multiplan Commercial |
$9.49
|
|
|
IVABRADINE 5 MG TABLET [204605]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 50742-362-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Senior |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
IVABRADINE 5 MG TABLET [204605]
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 50742-362-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
IVABRADINE 5 MG TABLET [204605]
|
Facility
|
OP
|
$12.65
|
|
|
Service Code
|
NDC 60687-862-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$10.75 |
| Rate for Payer: Adventist Health Commercial |
$2.53
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.49
|
| Rate for Payer: Blue Shield of California Commercial |
$7.72
|
| Rate for Payer: Blue Shield of California EPN |
$6.17
|
| Rate for Payer: Cash Price |
$6.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.75
|
| Rate for Payer: Dignity Health Senior |
$10.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.83
|
| Rate for Payer: Heritage Provider Network Senior |
$7.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.86
|
| Rate for Payer: Multiplan Commercial |
$9.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.06
|
| Rate for Payer: TriValley Medical Group Senior |
$5.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.75
|
| Rate for Payer: Vantage Medical Group Senior |
$10.75
|
|
|
IVABRADINE 5 MG TABLET [204605]
|
Facility
|
IP
|
$12.65
|
|
|
Service Code
|
NDC 60687-862-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$9.49 |
| Rate for Payer: Adventist Health Commercial |
$2.53
|
| Rate for Payer: Cash Price |
$6.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.56
|
| Rate for Payer: Heritage Provider Network Senior |
$8.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.16
|
| Rate for Payer: Multiplan Commercial |
$9.49
|
|
|
IVABRADINE 5 MG TABLET [204605]
|
Facility
|
IP
|
$2.70
|
|
|
Service Code
|
NDC 62332-679-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Senior |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
|
|
IVABRADINE 7.5 MG TABLET [204608]
|
Facility
|
OP
|
$12.52
|
|
|
Service Code
|
NDC 55513-810-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$10.64 |
| Rate for Payer: Adventist Health Commercial |
$2.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.39
|
| Rate for Payer: Blue Shield of California Commercial |
$7.64
|
| Rate for Payer: Blue Shield of California EPN |
$6.11
|
| Rate for Payer: Cash Price |
$6.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.64
|
| Rate for Payer: Dignity Health Senior |
$10.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.75
|
| Rate for Payer: Heritage Provider Network Senior |
$7.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.76
|
| Rate for Payer: Multiplan Commercial |
$9.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.01
|
| Rate for Payer: TriValley Medical Group Senior |
$5.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.64
|
| Rate for Payer: Vantage Medical Group Senior |
$10.64
|
|
|
IVABRADINE 7.5 MG TABLET [204608]
|
Facility
|
IP
|
$12.52
|
|
|
Service Code
|
NDC 55513-810-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$9.39 |
| Rate for Payer: Adventist Health Commercial |
$2.50
|
| Rate for Payer: Cash Price |
$6.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.48
|
| Rate for Payer: Heritage Provider Network Senior |
$8.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.13
|
| Rate for Payer: Multiplan Commercial |
$9.39
|
|
|
IVERMECTIN 3 MG TABLET [25820]
|
Facility
|
IP
|
$4.97
|
|
|
Service Code
|
NDC 42799-806-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$3.73 |
| Rate for Payer: Adventist Health Commercial |
$0.99
|
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.36
|
| Rate for Payer: Heritage Provider Network Senior |
$3.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$3.73
|
|
|
IVERMECTIN 3 MG TABLET [25820]
|
Facility
|
OP
|
$4.97
|
|
|
Service Code
|
NDC 42799-806-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Adventist Health Commercial |
$0.99
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.73
|
| Rate for Payer: Blue Shield of California Commercial |
$3.03
|
| Rate for Payer: Blue Shield of California EPN |
$2.43
|
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.22
|
| Rate for Payer: Dignity Health Senior |
$4.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.08
|
| Rate for Payer: Heritage Provider Network Senior |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.48
|
| Rate for Payer: Multiplan Commercial |
$3.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.99
|
| Rate for Payer: TriValley Medical Group Senior |
$1.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.22
|
| Rate for Payer: Vantage Medical Group Senior |
$4.22
|
|
|
KARAYA GUM TOPICAL POWDER [111957]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 8380007905
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| 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 Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
