|
CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [37567]
|
Facility
IP
|
$1.96
|
|
|
Service Code
|
NDC 66993-407-32
|
| Hospital Charge Code |
1710949
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.35
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.47
|
|
|
CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR [27634]
|
Facility
IP
|
$1.10
|
|
|
Service Code
|
NDC 0832-6022-11
|
| Hospital Charge Code |
1710877
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.76
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
|
|
CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR [27634]
|
Facility
OP
|
$1.10
|
|
|
Service Code
|
NDC 0781-8016-01
|
| Hospital Charge Code |
1710877
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.94
|
| Rate for Payer: Dignity Health Senior |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Vantage Medical Group Senior |
$0.94
|
|
|
CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR [27634]
|
Facility
OP
|
$1.10
|
|
|
Service Code
|
NDC 0832-6022-11
|
| Hospital Charge Code |
1710877
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.94
|
| Rate for Payer: Dignity Health Senior |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Vantage Medical Group Senior |
$0.94
|
|
|
CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR [27634]
|
Facility
IP
|
$1.10
|
|
|
Service Code
|
NDC 0781-8016-01
|
| Hospital Charge Code |
1710877
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.76
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
|
|
CARBAMAZEPINE ER 200 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [27632]
|
Facility
IP
|
$1.96
|
|
|
Service Code
|
NDC 66993-408-32
|
| Hospital Charge Code |
1710925
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.35
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.47
|
|
|
CARBAMAZEPINE ER 200 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [27632]
|
Facility
OP
|
$1.96
|
|
|
Service Code
|
NDC 66993-408-32
|
| Hospital Charge Code |
1710925
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.47
|
| Rate for Payer: Blue Shield of California Commercial |
$1.22
|
| Rate for Payer: Blue Shield of California EPN |
$1.15
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.67
|
| Rate for Payer: Dignity Health Senior |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Vantage Medical Group Senior |
$1.67
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR [27635]
|
Facility
IP
|
$2.00
|
|
|
Service Code
|
NDC 0781-5987-01
|
| Hospital Charge Code |
1711778
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR [27635]
|
Facility
OP
|
$4.04
|
|
|
Service Code
|
NDC 60687-583-21
|
| Hospital Charge Code |
1711778
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.43 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.03
|
| Rate for Payer: Blue Shield of California Commercial |
$2.51
|
| Rate for Payer: Blue Shield of California EPN |
$2.37
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.43
|
| Rate for Payer: Dignity Health Senior |
$3.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$3.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.43
|
| Rate for Payer: Vantage Medical Group Senior |
$3.43
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR [27635]
|
Facility
IP
|
$4.04
|
|
|
Service Code
|
NDC 60687-583-11
|
| Hospital Charge Code |
1711778
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.03 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.78
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.74
|
| Rate for Payer: Heritage Provider Network Senior |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$3.03
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR [27635]
|
Facility
OP
|
$0.96
|
|
|
Service Code
|
NDC 59746-790-01
|
| Hospital Charge Code |
1711778
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: Dignity Health Senior |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Senior |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR [27635]
|
Facility
IP
|
$0.96
|
|
|
Service Code
|
NDC 59746-790-01
|
| Hospital Charge Code |
1711778
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.66
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Senior |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR [27635]
|
Facility
OP
|
$2.00
|
|
|
Service Code
|
NDC 0781-5987-01
|
| Hospital Charge Code |
1711778
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR [27635]
|
Facility
IP
|
$4.04
|
|
|
Service Code
|
NDC 60687-583-21
|
| Hospital Charge Code |
1711778
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.03 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.78
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.74
|
| Rate for Payer: Heritage Provider Network Senior |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$3.03
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR [27635]
|
Facility
OP
|
$4.04
|
|
|
Service Code
|
NDC 60687-583-11
|
| Hospital Charge Code |
1711778
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.43 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.03
|
| Rate for Payer: Blue Shield of California Commercial |
$2.51
|
| Rate for Payer: Blue Shield of California EPN |
$2.37
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.43
|
| Rate for Payer: Dignity Health Senior |
$3.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$3.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.43
|
| Rate for Payer: Vantage Medical Group Senior |
$3.43
|
|
|
CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [27633]
|
Facility
OP
|
$1.96
|
|
|
Service Code
|
NDC 66993-409-32
|
| Hospital Charge Code |
1710903
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.47
|
| Rate for Payer: Blue Shield of California Commercial |
$1.22
|
| Rate for Payer: Blue Shield of California EPN |
$1.15
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.67
|
| Rate for Payer: Dignity Health Senior |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Vantage Medical Group Senior |
$1.67
|
|
|
CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [27633]
|
Facility
IP
|
$1.96
|
|
|
Service Code
|
NDC 66993-409-32
|
| Hospital Charge Code |
1710903
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.35
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.47
|
|
|
CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [27633]
|
Facility
OP
|
$2.13
|
|
|
Service Code
|
NDC 54092-173-12
|
| Hospital Charge Code |
1710903
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.81
|
| Rate for Payer: Dignity Health Senior |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Senior |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [27633]
|
Facility
IP
|
$2.13
|
|
|
Service Code
|
NDC 54092-173-12
|
| Hospital Charge Code |
1710903
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
|
|
CARBAMAZEPINE ER 400 MG TABLET,EXTENDED RELEASE,12 HR [27636]
|
Facility
IP
|
$7.49
|
|
|
Service Code
|
NDC 0078-0512-05
|
| Hospital Charge Code |
1711779
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.15
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.07
|
| Rate for Payer: Heritage Provider Network Senior |
$5.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.87
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
|
|
CARBAMAZEPINE ER 400 MG TABLET,EXTENDED RELEASE,12 HR [27636]
|
Facility
OP
|
$7.49
|
|
|
Service Code
|
NDC 0078-0512-05
|
| Hospital Charge Code |
1711779
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$6.37 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.62
|
| Rate for Payer: Blue Shield of California Commercial |
$4.65
|
| Rate for Payer: Blue Shield of California EPN |
$4.40
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.37
|
| Rate for Payer: Dignity Health Senior |
$6.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.64
|
| Rate for Payer: Heritage Provider Network Senior |
$4.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.87
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.37
|
| Rate for Payer: Vantage Medical Group Senior |
$6.37
|
|
|
CARBAMIDE PEROXIDE 10 % ORAL RINSE [1358]
|
Facility
IP
|
$0.34
|
|
|
Service Code
|
NDC 63029-500-01
|
| Hospital Charge Code |
1743241
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
CARBAMIDE PEROXIDE 10 % ORAL RINSE [1358]
|
Facility
OP
|
$0.34
|
|
|
Service Code
|
NDC 63029-500-01
|
| Hospital Charge Code |
1743241
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
IP
|
$0.24
|
|
|
Service Code
|
NDC 46122-556-05
|
| Hospital Charge Code |
1740102
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| 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 Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]
|
Facility
IP
|
$0.15
|
|
|
Service Code
|
NDC 0904-6627-35
|
| Hospital Charge Code |
1740102
|
|
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 |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
