|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]
|
Facility
IP
|
$0.46
|
|
|
Service Code
|
NDC 51079-978-20
|
| Hospital Charge Code |
1710890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]
|
Facility
IP
|
$0.45
|
|
|
Service Code
|
NDC 62756-461-88
|
| Hospital Charge Code |
1710890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.31
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]
|
Facility
OP
|
$0.46
|
|
|
Service Code
|
NDC 51079-978-01
|
| Hospital Charge Code |
1710890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Senior |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]
|
Facility
OP
|
$0.46
|
|
|
Service Code
|
NDC 51079-978-20
|
| Hospital Charge Code |
1710890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Senior |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
CARBIDOPA ER 36.25 MG-LEVODOPA 145 MG CAPSULE,EXTENDED RELEASE [208774]
|
Facility
IP
|
$4.99
|
|
|
Service Code
|
NDC 64896-662-01
|
| Hospital Charge Code |
ERX208774
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.43
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.38
|
| Rate for Payer: Heritage Provider Network Senior |
$3.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: Multiplan Commercial |
$3.74
|
|
|
CARBIDOPA ER 36.25 MG-LEVODOPA 145 MG CAPSULE,EXTENDED RELEASE [208774]
|
Facility
OP
|
$4.99
|
|
|
Service Code
|
NDC 64896-662-01
|
| Hospital Charge Code |
ERX208774
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.74
|
| Rate for Payer: Blue Shield of California Commercial |
$3.10
|
| Rate for Payer: Blue Shield of California EPN |
$2.93
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.24
|
| Rate for Payer: Dignity Health Senior |
$4.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.09
|
| Rate for Payer: Heritage Provider Network Senior |
$3.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: Multiplan Commercial |
$3.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.24
|
| Rate for Payer: Vantage Medical Group Senior |
$4.24
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
OP
|
$0.87
|
|
|
Service Code
|
NDC 68084-282-01
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: Dignity Health Senior |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Senior |
$0.74
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
IP
|
$1.07
|
|
|
Service Code
|
NDC 51079-923-01
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
OP
|
$1.07
|
|
|
Service Code
|
NDC 51079-923-01
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.91
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.91
|
| Rate for Payer: Dignity Health Senior |
$0.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Senior |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.91
|
| Rate for Payer: Vantage Medical Group Senior |
$0.91
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
OP
|
$0.87
|
|
|
Service Code
|
NDC 68084-282-11
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: Dignity Health Senior |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Senior |
$0.74
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
OP
|
$1.07
|
|
|
Service Code
|
NDC 51079-923-20
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.91
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.91
|
| Rate for Payer: Dignity Health Senior |
$0.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Senior |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.91
|
| Rate for Payer: Vantage Medical Group Senior |
$0.91
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
IP
|
$1.07
|
|
|
Service Code
|
NDC 51079-923-20
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
IP
|
$0.87
|
|
|
Service Code
|
NDC 68084-282-01
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| 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 Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
OP
|
$0.84
|
|
|
Service Code
|
NDC 62756-457-88
|
| Hospital Charge Code |
1711602
|
|
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
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
IP
|
$0.84
|
|
|
Service Code
|
NDC 62756-457-88
|
| Hospital Charge Code |
1711602
|
|
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
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
IP
|
$0.87
|
|
|
Service Code
|
NDC 68084-282-11
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| 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 Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
CARBIDOPA ER 61.25 MG-LEVODOPA 245 MG CAPSULE,EXTENDED RELEASE [208776]
|
Facility
IP
|
$6.27
|
|
|
Service Code
|
NDC 64896-664-01
|
| Hospital Charge Code |
ERX208776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$4.70 |
| Rate for Payer: Adventist Health Commercial |
$1.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.31
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.24
|
| Rate for Payer: Heritage Provider Network Senior |
$4.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$4.70
|
|
|
CARBIDOPA ER 61.25 MG-LEVODOPA 245 MG CAPSULE,EXTENDED RELEASE [208776]
|
Facility
OP
|
$6.27
|
|
|
Service Code
|
NDC 64896-664-01
|
| Hospital Charge Code |
ERX208776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Adventist Health Commercial |
$1.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.70
|
| Rate for Payer: Blue Shield of California Commercial |
$3.89
|
| Rate for Payer: Blue Shield of California EPN |
$3.68
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.33
|
| Rate for Payer: Dignity Health Senior |
$5.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.88
|
| Rate for Payer: Heritage Provider Network Senior |
$3.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$4.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.33
|
| Rate for Payer: Vantage Medical Group Senior |
$5.33
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
OP
|
$2.17
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
1755737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$254.87 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$254.87
|
| Rate for Payer: Blue Shield of California Commercial |
$7.51
|
| Rate for Payer: Blue Shield of California EPN |
$7.51
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.84
|
| Rate for Payer: Dignity Health Senior |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: IEHP Medi-Cal |
$12.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.84
|
| Rate for Payer: Vantage Medical Group Senior |
$1.84
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
IP
|
$2.17
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
1755737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.49
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.73
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
OP
|
$1.18
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
1755491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$254.87 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$254.87
|
| Rate for Payer: Blue Shield of California Commercial |
$7.51
|
| Rate for Payer: Blue Shield of California EPN |
$7.51
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.00
|
| Rate for Payer: Dignity Health Senior |
$1.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: IEHP Medi-Cal |
$12.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1.00
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
IP
|
$1.14
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
1755740
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.67
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
OP
|
$2.18
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
NDG39265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$254.87 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$254.87
|
| Rate for Payer: Blue Shield of California Commercial |
$7.51
|
| Rate for Payer: Blue Shield of California EPN |
$7.51
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.85
|
| Rate for Payer: Dignity Health Senior |
$1.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.01
|
| Rate for Payer: Heritage Provider Network Senior |
$1.01
|
| Rate for Payer: IEHP Medi-Cal |
$12.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1.85
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
IP
|
$1.18
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
1755491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.81
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.39
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
IP
|
$2.18
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
NDG39265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.50
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.73
|
|
