|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
OP
|
$0.83
|
|
|
Service Code
|
NDC 50268-451-15
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Senior |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
OP
|
$0.63
|
|
|
Service Code
|
NDC 68084-591-11
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
IP
|
$0.63
|
|
|
Service Code
|
NDC 68084-591-01
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
OP
|
$0.83
|
|
|
Service Code
|
NDC 50268-451-11
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Senior |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
NDC 50742-175-01
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
IP
|
$0.83
|
|
|
Service Code
|
NDC 50268-451-11
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| 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 Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
OP
|
$0.63
|
|
|
Service Code
|
NDC 68084-591-01
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
OP
|
$0.25
|
|
|
Service Code
|
NDC 62175-128-37
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Senior |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
IP
|
$0.25
|
|
|
Service Code
|
NDC 62175-128-37
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| 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 Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
OP
|
$0.14
|
|
|
Service Code
|
NDC 50742-175-01
|
| Hospital Charge Code |
1711758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
IP
|
$0.16
|
|
|
Service Code
|
NDC 50742-176-01
|
| Hospital Charge Code |
1711622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
IP
|
$0.84
|
|
|
Service Code
|
NDC 68084-592-11
|
| Hospital Charge Code |
1711622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.58
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Senior |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
OP
|
$0.26
|
|
|
Service Code
|
NDC 62175-119-37
|
| Hospital Charge Code |
1711622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| 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 |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| 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 |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
OP
|
$0.16
|
|
|
Service Code
|
NDC 50742-176-01
|
| Hospital Charge Code |
1711622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: 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 |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
IP
|
$0.26
|
|
|
Service Code
|
NDC 62175-119-37
|
| Hospital Charge Code |
1711622
|
|
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 |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| 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
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
OP
|
$0.84
|
|
|
Service Code
|
NDC 68084-592-11
|
| Hospital Charge Code |
1711622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.63
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Senior |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Senior |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION [10358]
|
Facility
OP
|
$150.96
|
|
|
Service Code
|
CPT Q9968
|
| Hospital Charge Code |
1721183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$113.22 |
| Rate for Payer: Adventist Health Commercial |
$30.19
|
| Rate for Payer: Adventist Health Commercial |
$50.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$42.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$42.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$103.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$174.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$93.75
|
| Rate for Payer: Blue Shield of California Commercial |
$158.11
|
| Rate for Payer: Blue Shield of California EPN |
$149.46
|
| Rate for Payer: Blue Shield of California EPN |
$88.61
|
| Rate for Payer: Cash Price |
$67.93
|
| Rate for Payer: Cash Price |
$114.57
|
| Rate for Payer: Cash Price |
$67.93
|
| Rate for Payer: Cash Price |
$114.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$117.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.74
|
| Rate for Payer: Dignity Health Senior |
$8.74
|
| Rate for Payer: Dignity Health Senior |
$8.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.95
|
| Rate for Payer: EPIC Health Plan Medicare |
$7.95
|
| Rate for Payer: EPIC Health Plan Medicare |
$7.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$117.88
|
| Rate for Payer: Heritage Provider Network Senior |
$117.88
|
| Rate for Payer: Heritage Provider Network Senior |
$69.89
|
| Rate for Payer: Humana Medicare |
$7.95
|
| Rate for Payer: Humana Medicare |
$7.95
|
| Rate for Payer: IEHP Medi-Cal |
$29.08
|
| Rate for Payer: IEHP Medi-Cal |
$29.08
|
| Rate for Payer: IEHP Medicare Advantage |
$7.95
|
| Rate for Payer: IEHP Medicare Advantage |
$7.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.02
|
| Rate for Payer: Multiplan Commercial |
$190.96
|
| Rate for Payer: Multiplan Commercial |
$113.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.74
|
| Rate for Payer: TriValley Medical Group Senior |
$7.95
|
| Rate for Payer: TriValley Medical Group Senior |
$7.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$92.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$55.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$85.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$50.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.74
|
| Rate for Payer: Vantage Medical Group Senior |
$7.95
|
| Rate for Payer: Vantage Medical Group Senior |
$7.95
|
|
|
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION [10358]
|
Facility
IP
|
$254.61
|
|
|
Service Code
|
CPT Q9968
|
| Hospital Charge Code |
1721183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.08 |
| Max. Negotiated Rate |
$190.96 |
| Rate for Payer: Adventist Health Commercial |
$50.92
|
| Rate for Payer: Adventist Health Commercial |
$30.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$103.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$174.92
|
| Rate for Payer: Cash Price |
$67.93
|
| Rate for Payer: Cash Price |
$114.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$117.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$172.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$102.20
|
| Rate for Payer: Heritage Provider Network Senior |
$102.20
|
| Rate for Payer: Heritage Provider Network Senior |
$172.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.65
|
| Rate for Payer: Multiplan Commercial |
$113.22
|
| Rate for Payer: Multiplan Commercial |
$190.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$55.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$92.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$50.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$85.07
|
|
|
ISOTRETINOIN 10 MG CAPSULE [10359]
|
Facility
OP
|
$6.02
|
|
|
Service Code
|
NDC 0378-6611-93
|
| Hospital Charge Code |
1710001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.52
|
| Rate for Payer: Blue Shield of California Commercial |
$3.74
|
| Rate for Payer: Blue Shield of California EPN |
$3.53
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.12
|
| Rate for Payer: Dignity Health Senior |
$5.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.73
|
| Rate for Payer: Heritage Provider Network Senior |
$3.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.12
|
| Rate for Payer: Vantage Medical Group Senior |
$5.12
|
|
|
ISOTRETINOIN 10 MG CAPSULE [10359]
|
Facility
OP
|
$8.58
|
|
|
Service Code
|
NDC 61748-301-13
|
| Hospital Charge Code |
1710001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$7.29 |
| Rate for Payer: Adventist Health Commercial |
$1.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.44
|
| Rate for Payer: Blue Shield of California Commercial |
$5.33
|
| Rate for Payer: Blue Shield of California EPN |
$5.04
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.29
|
| Rate for Payer: Dignity Health Senior |
$7.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.31
|
| Rate for Payer: Heritage Provider Network Senior |
$5.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$6.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.29
|
| Rate for Payer: Vantage Medical Group Senior |
$7.29
|
|
|
ISOTRETINOIN 10 MG CAPSULE [10359]
|
Facility
IP
|
$6.02
|
|
|
Service Code
|
NDC 0378-6611-93
|
| Hospital Charge Code |
1710001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.14
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.08
|
| Rate for Payer: Heritage Provider Network Senior |
$4.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
|
|
ISOTRETINOIN 10 MG CAPSULE [10359]
|
Facility
IP
|
$8.58
|
|
|
Service Code
|
NDC 61748-301-13
|
| Hospital Charge Code |
1710001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Adventist Health Commercial |
$1.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.89
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.81
|
| Rate for Payer: Heritage Provider Network Senior |
$5.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$6.44
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
OP
|
$7.14
|
|
|
Service Code
|
NDC 0378-6612-93
|
| Hospital Charge Code |
1710827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.36
|
| Rate for Payer: Blue Shield of California Commercial |
$4.43
|
| Rate for Payer: Blue Shield of California EPN |
$4.19
|
| Rate for Payer: Cash Price |
$3.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.07
|
| Rate for Payer: Dignity Health Senior |
$6.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.42
|
| Rate for Payer: Heritage Provider Network Senior |
$4.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.07
|
| Rate for Payer: Vantage Medical Group Senior |
$6.07
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
IP
|
$16.83
|
|
|
Service Code
|
NDC 0555-1055-56
|
| Hospital Charge Code |
1710827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$12.62 |
| Rate for Payer: Adventist Health Commercial |
$3.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.56
|
| Rate for Payer: Cash Price |
$7.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.39
|
| Rate for Payer: Heritage Provider Network Senior |
$11.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.21
|
| Rate for Payer: Multiplan Commercial |
$12.62
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
OP
|
$16.83
|
|
|
Service Code
|
NDC 0555-1055-56
|
| Hospital Charge Code |
1710827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$14.31 |
| Rate for Payer: Adventist Health Commercial |
$3.37
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.62
|
| Rate for Payer: Blue Shield of California Commercial |
$10.45
|
| Rate for Payer: Blue Shield of California EPN |
$9.88
|
| Rate for Payer: Cash Price |
$7.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.31
|
| Rate for Payer: Dignity Health Senior |
$14.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.42
|
| Rate for Payer: Heritage Provider Network Senior |
$10.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.21
|
| Rate for Payer: Multiplan Commercial |
$12.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.31
|
| Rate for Payer: Vantage Medical Group Senior |
$14.31
|
|
