|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
IP
|
$1.80
|
|
|
Service Code
|
NDC 50268-140-11
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
OP
|
$1.58
|
|
|
Service Code
|
NDC 0904-7084-04
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.93
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.34
|
| Rate for Payer: Dignity Health Senior |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.98
|
| Rate for Payer: Heritage Provider Network Senior |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: Vantage Medical Group Senior |
$1.34
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]
|
Facility
OP
|
$1.80
|
|
|
Service Code
|
NDC 50268-140-13
|
| Hospital Charge Code |
1712279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Senior |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
IP
|
$0.94
|
|
|
Service Code
|
NDC 68001-321-04
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| 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 |
$0.71
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
OP
|
$0.27
|
|
|
Service Code
|
NDC 16729-444-10
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| 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 |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| 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 |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
OP
|
$0.94
|
|
|
Service Code
|
NDC 68001-321-04
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.80
|
| Rate for Payer: Dignity Health Senior |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| 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 Commercial |
$0.45
|
| 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 |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
OP
|
$3.04
|
|
|
Service Code
|
NDC 68084-252-21
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.58
|
| Rate for Payer: Dignity Health Senior |
$2.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.88
|
| Rate for Payer: Heritage Provider Network Senior |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.58
|
| Rate for Payer: Vantage Medical Group Senior |
$2.58
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
IP
|
$0.48
|
|
|
Service Code
|
NDC 63304-724-30
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
IP
|
$3.04
|
|
|
Service Code
|
NDC 68084-252-11
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.09
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.06
|
| Rate for Payer: Heritage Provider Network Senior |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
OP
|
$3.04
|
|
|
Service Code
|
NDC 68084-252-11
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.58
|
| Rate for Payer: Dignity Health Senior |
$2.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.88
|
| Rate for Payer: Heritage Provider Network Senior |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.58
|
| Rate for Payer: Vantage Medical Group Senior |
$2.58
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
OP
|
$0.48
|
|
|
Service Code
|
NDC 63304-724-30
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Senior |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| 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 Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
IP
|
$0.27
|
|
|
Service Code
|
NDC 16729-444-10
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| 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 |
$0.20
|
|
|
BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE [36776]
|
Facility
IP
|
$3.04
|
|
|
Service Code
|
NDC 68084-252-21
|
| Hospital Charge Code |
1712280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.09
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.06
|
| Rate for Payer: Heritage Provider Network Senior |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS
|
Facility
IP
|
$10,562.81
|
|
|
Service Code
|
APR-DRG 8421
|
| Min. Negotiated Rate |
$10,562.81 |
| Max. Negotiated Rate |
$10,562.81 |
| Rate for Payer: IEHP Medi-Cal |
$10,562.81
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS
|
Facility
IP
|
$74,944.52
|
|
|
Service Code
|
APR-DRG 8424
|
| Min. Negotiated Rate |
$74,944.52 |
| Max. Negotiated Rate |
$74,944.52 |
| Rate for Payer: IEHP Medi-Cal |
$74,944.52
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS
|
Facility
IP
|
$16,383.95
|
|
|
Service Code
|
APR-DRG 8422
|
| Min. Negotiated Rate |
$16,383.95 |
| Max. Negotiated Rate |
$16,383.95 |
| Rate for Payer: IEHP Medi-Cal |
$16,383.95
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS
|
Facility
IP
|
$30,906.45
|
|
|
Service Code
|
APR-DRG 8423
|
| Min. Negotiated Rate |
$30,906.45 |
| Max. Negotiated Rate |
$30,906.45 |
| Rate for Payer: IEHP Medi-Cal |
$30,906.45
|
|
|
BUSPIRONE 10 MG TABLET [9323]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 29300-245-01
|
| Hospital Charge Code |
1712134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| 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 Commercial |
$0.04
|
| 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 |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
BUSPIRONE 10 MG TABLET [9323]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 68382-181-01
|
| Hospital Charge Code |
1712134
|
|
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: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| 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
|
|
|
BUSPIRONE 10 MG TABLET [9323]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 16729-202-01
|
| Hospital Charge Code |
1712134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
BUSPIRONE 10 MG TABLET [9323]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
NDC 51079-986-20
|
| Hospital Charge Code |
1712134
|
|
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 |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| 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 |
$0.11
|
| 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 |
$0.08
|
| 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: Multiplan Commercial |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
BUSPIRONE 10 MG TABLET [9323]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
NDC 64380-742-06
|
| Hospital Charge Code |
1712134
|
|
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: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| 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
|
|
|
BUSPIRONE 10 MG TABLET [9323]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 68382-181-01
|
| Hospital Charge Code |
1712134
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| 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: Multiplan Commercial |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
BUSPIRONE 10 MG TABLET [9323]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 51079-986-01
|
| Hospital Charge Code |
1712134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| 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 |
$0.13
|
|
|
BUSPIRONE 10 MG TABLET [9323]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 51079-986-20
|
| Hospital Charge Code |
1712134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| 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 |
$0.13
|
|
