|
LAMOTRIGINE 25 MG CHEWABLE DISPERSIBLE TABLET [103880]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 6233209631
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Senior |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
LAMOTRIGINE 25 MG CHEWABLE DISPERSIBLE TABLET [103880]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 6233209631
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
LAMOTRIGINE 25 MG CHEWABLE DISPERSIBLE TABLET [103880]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 1657178601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
LAMOTRIGINE 25 MG CHEWABLE DISPERSIBLE TABLET [103880]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 1657178601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
LAMOTRIGINE 25 MG DISINTEGRATING TABLET [97830]
|
Facility
|
IP
|
$16.07
|
|
|
Service Code
|
NDC 0173077202
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: Adventist Health Commercial |
$3.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.35
|
| Rate for Payer: Cash Price |
$7.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.88
|
| Rate for Payer: Heritage Provider Network Senior |
$10.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.02
|
| Rate for Payer: Multiplan Commercial |
$12.05
|
|
|
LAMOTRIGINE 25 MG DISINTEGRATING TABLET [97830]
|
Facility
|
OP
|
$16.07
|
|
|
Service Code
|
NDC 0173077202
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$13.66 |
| Rate for Payer: Adventist Health Commercial |
$3.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.04
|
| Rate for Payer: Blue Shield of California Commercial |
$9.80
|
| Rate for Payer: Blue Shield of California EPN |
$7.84
|
| Rate for Payer: Cash Price |
$7.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.95
|
| Rate for Payer: Heritage Provider Network Senior |
$9.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.25
|
| Rate for Payer: Multiplan Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.43
|
| Rate for Payer: TriValley Medical Group Senior |
$6.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.66
|
| Rate for Payer: Vantage Medical Group Senior |
$13.66
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 2930011101
|
| 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: 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 Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 6808431811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 6808431811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 6808431801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 6808431801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 2930011101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 6233203731
|
| Hospital Charge Code |
901700029
|
|
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 Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 6233203731
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.04
|
| 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 Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
|
IP
|
$4.24
|
|
|
Service Code
|
NDC 2724118430
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: Adventist Health Commercial |
$0.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.73
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.87
|
| Rate for Payer: Heritage Provider Network Senior |
$2.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: Multiplan Commercial |
$3.18
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
|
IP
|
$6.41
|
|
|
Service Code
|
NDC 4359855130
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$4.81 |
| Rate for Payer: Adventist Health Commercial |
$1.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.13
|
| Rate for Payer: Cash Price |
$2.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.34
|
| Rate for Payer: Heritage Provider Network Senior |
$4.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: Multiplan Commercial |
$4.81
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
|
OP
|
$4.24
|
|
|
Service Code
|
NDC 2724118430
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Adventist Health Commercial |
$0.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.12
|
| Rate for Payer: Blue Shield of California Commercial |
$2.59
|
| Rate for Payer: Blue Shield of California EPN |
$2.07
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.62
|
| Rate for Payer: Heritage Provider Network Senior |
$2.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.97
|
| Rate for Payer: Multiplan Commercial |
$3.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.70
|
| Rate for Payer: TriValley Medical Group Senior |
$1.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.60
|
| Rate for Payer: Vantage Medical Group Senior |
$3.60
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
|
OP
|
$6.41
|
|
|
Service Code
|
NDC 4359855130
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$5.45 |
| Rate for Payer: Adventist Health Commercial |
$1.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.21
|
| Rate for Payer: Blue Shield of California Commercial |
$3.91
|
| Rate for Payer: Blue Shield of California EPN |
$3.13
|
| Rate for Payer: Cash Price |
$2.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.97
|
| Rate for Payer: Heritage Provider Network Senior |
$3.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.49
|
| Rate for Payer: Multiplan Commercial |
$4.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.56
|
| Rate for Payer: TriValley Medical Group Senior |
$2.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.45
|
| Rate for Payer: Vantage Medical Group Senior |
$5.45
|
|
|
LAMOTRIGINE 5 MG CHEWABLE DISPERSIBLE TABLET [104568]
|
Facility
|
OP
|
$11.42
|
|
|
Service Code
|
NDC 0173052600
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$9.71 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.71
|
| Rate for Payer: Blue Shield of California Commercial |
$6.97
|
| Rate for Payer: Blue Shield of California EPN |
$5.57
|
| Rate for Payer: Cash Price |
$5.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.07
|
| Rate for Payer: Heritage Provider Network Senior |
$7.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7.99
|
| Rate for Payer: Multiplan Commercial |
$8.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.57
|
| Rate for Payer: TriValley Medical Group Senior |
$4.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.71
|
| Rate for Payer: Vantage Medical Group Senior |
$9.71
|
|
|
LAMOTRIGINE 5 MG CHEWABLE DISPERSIBLE TABLET [104568]
|
Facility
|
IP
|
$11.42
|
|
|
Service Code
|
NDC 0173052600
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$8.56 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.35
|
| Rate for Payer: Cash Price |
$5.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.73
|
| Rate for Payer: Heritage Provider Network Senior |
$7.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$8.56
|
|
|
LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM [120012]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 7214003868
|
| 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 Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM [120012]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 7214003868
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| 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 |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| 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 Foundation Hospitals Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| 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 |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
LANOLIN-MINERAL OIL LOTION [2787]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 7214011019
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
LANOLIN-MINERAL OIL LOTION [2787]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 7214011019
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| 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 |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
LANREOTIDE 60 MG/0.2 ML SUBCUTANEOUS SYRINGE [88570]
|
Facility
|
OP
|
$40,158.00
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.43 |
| Max. Negotiated Rate |
$30,118.50 |
| Rate for Payer: Adventist Health Commercial |
$8,031.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24,817.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$46.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$41.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$63.48
|
| Rate for Payer: Blue Shield of California Commercial |
$41.83
|
| Rate for Payer: Blue Shield of California EPN |
$41.83
|
| Rate for Payer: Cash Price |
$18,071.10
|
| Rate for Payer: Cash Price |
$18,071.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18,472.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$46.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$41.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$41.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$25,701.12
|
| Rate for Payer: EPIC Health Plan Medicare |
$37.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$18,593.15
|
| Rate for Payer: Heritage Provider Network Senior |
$18,593.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$19,155.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7,268.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$43.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10,039.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50.16
|
| Rate for Payer: Multiplan Commercial |
$30,118.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$16,063.20
|
| Rate for Payer: TriValley Medical Group Senior |
$16,063.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14,509.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13,296.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$46.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$41.17
|
| Rate for Payer: Vantage Medical Group Senior |
$41.17
|
|
