|
LAMOTRIGINE 200 MG TABLET [13983]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 51672-4133-4
|
| Hospital Charge Code |
1711641
|
|
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
|
|
|
LAMOTRIGINE 25 MG CHEWABLE DISPERSIBLE TABLET [103880]
|
Facility
IP
|
$0.53
|
|
|
Service Code
|
NDC 68462-229-01
|
| Hospital Charge Code |
1711994
|
|
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 |
$0.36
|
| 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 Permanente of CA 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
OP
|
$0.53
|
|
|
Service Code
|
NDC 62332-096-31
|
| Hospital Charge Code |
1711994
|
|
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 Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| 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
OP
|
$0.53
|
|
|
Service Code
|
NDC 68462-229-01
|
| Hospital Charge Code |
1711994
|
|
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 Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| 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 62332-096-31
|
| Hospital Charge Code |
1711994
|
|
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 |
$0.36
|
| 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 Permanente of CA 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 DISINTEGRATING TABLET [97830]
|
Facility
IP
|
$16.07
|
|
|
Service Code
|
NDC 0173-0772-02
|
| Hospital Charge Code |
1712434
|
|
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 |
$11.04
|
| 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 Permanente of CA 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 0173-0772-02
|
| Hospital Charge Code |
1712434
|
|
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 Gatekeeper |
$8.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Blue Shield of California Commercial |
$9.98
|
| Rate for Payer: Blue Shield of California EPN |
$9.43
|
| 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 Senior |
$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 Permanente of CA Commercial |
$7.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.02
|
| Rate for Payer: Multiplan Commercial |
$12.05
|
| 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 29300-111-01
|
| Hospital Charge Code |
1711638
|
|
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
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 29300-111-01
|
| Hospital Charge Code |
1711638
|
|
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 Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.03
|
| 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
|
| 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
|
$0.07
|
|
|
Service Code
|
NDC 13668-045-01
|
| Hospital Charge Code |
1711638
|
|
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
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
OP
|
$0.22
|
|
|
Service Code
|
NDC 68084-318-11
|
| Hospital Charge Code |
1711638
|
|
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 Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| 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 68084-318-11
|
| Hospital Charge Code |
1711638
|
|
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 |
$0.15
|
| 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 Permanente of CA 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 13668-045-01
|
| Hospital Charge Code |
1711638
|
|
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 Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.03
|
| 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
|
| 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
OP
|
$0.07
|
|
|
Service Code
|
NDC 51672-4130-1
|
| Hospital Charge Code |
1711638
|
|
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 Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.03
|
| 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
|
| 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
|
$0.07
|
|
|
Service Code
|
NDC 51672-4130-1
|
| Hospital Charge Code |
1711638
|
|
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
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
OP
|
$9.13
|
|
|
Service Code
|
NDC 0115-9940-68
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Adventist Health Commercial |
$1.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.85
|
| Rate for Payer: Blue Shield of California Commercial |
$5.67
|
| Rate for Payer: Blue Shield of California EPN |
$5.36
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.76
|
| Rate for Payer: Dignity Health Senior |
$7.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.65
|
| Rate for Payer: Heritage Provider Network Senior |
$5.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.76
|
| Rate for Payer: Vantage Medical Group Senior |
$7.76
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
IP
|
$6.36
|
|
|
Service Code
|
NDC 27241-184-30
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Adventist Health Commercial |
$1.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.37
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.31
|
| Rate for Payer: Heritage Provider Network Senior |
$4.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$4.77
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
OP
|
$9.13
|
|
|
Service Code
|
NDC 49884-485-11
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Adventist Health Commercial |
$1.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.85
|
| Rate for Payer: Blue Shield of California Commercial |
$5.67
|
| Rate for Payer: Blue Shield of California EPN |
$5.36
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.76
|
| Rate for Payer: Dignity Health Senior |
$7.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.65
|
| Rate for Payer: Heritage Provider Network Senior |
$5.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.76
|
| Rate for Payer: Vantage Medical Group Senior |
$7.76
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
IP
|
$9.13
|
|
|
Service Code
|
NDC 49884-485-11
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$6.85 |
| Rate for Payer: Adventist Health Commercial |
$1.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.27
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.18
|
| Rate for Payer: Heritage Provider Network Senior |
$6.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
IP
|
$9.13
|
|
|
Service Code
|
NDC 49884-485-54
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$6.85 |
| Rate for Payer: Adventist Health Commercial |
$1.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.27
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.18
|
| Rate for Payer: Heritage Provider Network Senior |
$6.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
OP
|
$9.13
|
|
|
Service Code
|
NDC 49884-485-54
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Adventist Health Commercial |
$1.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.85
|
| Rate for Payer: Blue Shield of California Commercial |
$5.67
|
| Rate for Payer: Blue Shield of California EPN |
$5.36
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.76
|
| Rate for Payer: Dignity Health Senior |
$7.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.65
|
| Rate for Payer: Heritage Provider Network Senior |
$5.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.76
|
| Rate for Payer: Vantage Medical Group Senior |
$7.76
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
IP
|
$9.13
|
|
|
Service Code
|
NDC 0115-9940-68
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$6.85 |
| Rate for Payer: Adventist Health Commercial |
$1.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.27
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.18
|
| Rate for Payer: Heritage Provider Network Senior |
$6.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$6.85
|
|
|
LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]
|
Facility
OP
|
$6.36
|
|
|
Service Code
|
NDC 27241-184-30
|
| Hospital Charge Code |
1712435
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$5.41 |
| Rate for Payer: Adventist Health Commercial |
$1.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.77
|
| Rate for Payer: Blue Shield of California Commercial |
$3.95
|
| Rate for Payer: Blue Shield of California EPN |
$3.73
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.41
|
| Rate for Payer: Dignity Health Senior |
$5.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.94
|
| Rate for Payer: Heritage Provider Network Senior |
$3.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$4.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.41
|
| Rate for Payer: Vantage Medical Group Senior |
$5.41
|
|
|
LAMOTRIGINE 5 MG CHEWABLE DISPERSIBLE TABLET [104568]
|
Facility
IP
|
$18.48
|
|
|
Service Code
|
NDC 0173-0526-00
|
| Hospital Charge Code |
1711792
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$13.86 |
| Rate for Payer: Adventist Health Commercial |
$3.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.70
|
| Rate for Payer: Cash Price |
$8.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.51
|
| Rate for Payer: Heritage Provider Network Senior |
$12.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: Multiplan Commercial |
$13.86
|
|
|
LAMOTRIGINE 5 MG CHEWABLE DISPERSIBLE TABLET [104568]
|
Facility
OP
|
$18.48
|
|
|
Service Code
|
NDC 0173-0526-00
|
| Hospital Charge Code |
1711792
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Adventist Health Commercial |
$3.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$15.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.86
|
| Rate for Payer: Blue Shield of California Commercial |
$11.48
|
| Rate for Payer: Blue Shield of California EPN |
$10.85
|
| Rate for Payer: Cash Price |
$8.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.71
|
| Rate for Payer: Dignity Health Senior |
$15.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.44
|
| Rate for Payer: Heritage Provider Network Senior |
$11.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: Multiplan Commercial |
$13.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.71
|
| Rate for Payer: Vantage Medical Group Senior |
$15.71
|
|
