|
PYRIDOSTIGMINE BROMIDE 60 MG TABLET [11239]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
NDC 6838265906
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Senior |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.49
|
| Rate for Payer: TriValley Medical Group Senior |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Vantage Medical Group Senior |
$1.04
|
|
|
PYRIDOSTIGMINE BROMIDE 60 MG TABLET [11239]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
NDC 7193002890
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Senior |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.49
|
| Rate for Payer: TriValley Medical Group Senior |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Vantage Medical Group Senior |
$1.04
|
|
|
PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE [11240]
|
Facility
|
IP
|
$7.96
|
|
|
Service Code
|
NDC 6498022003
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$5.97 |
| Rate for Payer: Adventist Health Commercial |
$1.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.13
|
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.39
|
| Rate for Payer: Heritage Provider Network Senior |
$5.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.99
|
| Rate for Payer: Multiplan Commercial |
$5.97
|
|
|
PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE [11240]
|
Facility
|
OP
|
$7.96
|
|
|
Service Code
|
NDC 6498022003
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$6.77 |
| Rate for Payer: Adventist Health Commercial |
$1.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.98
|
| Rate for Payer: Blue Shield of California Commercial |
$4.86
|
| Rate for Payer: Blue Shield of California EPN |
$3.88
|
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.93
|
| Rate for Payer: Heritage Provider Network Senior |
$4.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.57
|
| Rate for Payer: Multiplan Commercial |
$5.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.18
|
| Rate for Payer: TriValley Medical Group Senior |
$3.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.77
|
| Rate for Payer: Vantage Medical Group Senior |
$6.77
|
|
|
PYRIDOXINE ORAL SOLUTION (IV FORM) 100 MG/ML [4080441]
|
Facility
|
OP
|
$10.79
|
|
|
Service Code
|
NDC 9994080441
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$9.17 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.40
|
| Rate for Payer: Blue Shield of California Commercial |
$6.58
|
| Rate for Payer: Blue Shield of California EPN |
$5.27
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.68
|
| Rate for Payer: Heritage Provider Network Senior |
$6.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7.55
|
| Rate for Payer: Multiplan Commercial |
$8.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.32
|
| Rate for Payer: TriValley Medical Group Senior |
$4.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.17
|
| Rate for Payer: Vantage Medical Group Senior |
$9.17
|
|
|
PYRIDOXINE ORAL SOLUTION (IV FORM) 100 MG/ML [4080441]
|
Facility
|
IP
|
$10.79
|
|
|
Service Code
|
NDC 9994080441
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$8.09 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.95
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.30
|
| Rate for Payer: Heritage Provider Network Senior |
$7.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$8.09
|
|
|
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION [6744]
|
Facility
|
OP
|
$29.72
|
|
|
Service Code
|
HCPCS J3415
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.38 |
| Max. Negotiated Rate |
$25.26 |
| Rate for Payer: Adventist Health Commercial |
$5.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.76
|
| Rate for Payer: Blue Shield of California Commercial |
$22.17
|
| Rate for Payer: Blue Shield of California EPN |
$22.17
|
| Rate for Payer: Cash Price |
$13.37
|
| Rate for Payer: Cash Price |
$13.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$25.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.76
|
| Rate for Payer: Heritage Provider Network Senior |
$13.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20.80
|
| Rate for Payer: Multiplan Commercial |
$22.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.89
|
| Rate for Payer: TriValley Medical Group Senior |
$11.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.26
|
| Rate for Payer: Vantage Medical Group Senior |
$25.26
|
|
|
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION [6744]
|
Facility
|
IP
|
$29.72
|
|
|
Service Code
|
HCPCS J3415
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.38 |
| Max. Negotiated Rate |
$22.29 |
| Rate for Payer: Adventist Health Commercial |
$5.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.14
|
| Rate for Payer: Cash Price |
$13.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.76
|
| Rate for Payer: Heritage Provider Network Senior |
$13.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.43
|
| Rate for Payer: Multiplan Commercial |
$22.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.84
|
|
|
PYRIDOXINE (VITAMIN B6) 100 MG TABLET [6745]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8770140730
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PYRIDOXINE (VITAMIN B6) 100 MG TABLET [6745]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 8770140730
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
PYRIDOXINE (VITAMIN B6) 25 MG TABLET [6746]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 0536440601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
PYRIDOXINE (VITAMIN B6) 25 MG TABLET [6746]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 0536440601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 5789685301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 5026885815
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 5026885811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 5026885811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 5026885815
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 5789685301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
PYRIDOXINE (VITAMIN B6) ORAL SOLUTION COMPOUND 1 MG/ML [4081140]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 9994081140
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
PYRIDOXINE (VITAMIN B6) ORAL SOLUTION COMPOUND 1 MG/ML [4081140]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 9994081140
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
PYRIMETHAMINE 25 MG TABLET [11246]
|
Facility
|
OP
|
$307.80
|
|
|
Service Code
|
NDC 0480372056
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.71 |
| Max. Negotiated Rate |
$261.63 |
| Rate for Payer: Adventist Health Commercial |
$61.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$190.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$261.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$169.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$230.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$153.96
|
| Rate for Payer: Blue Shield of California Commercial |
$187.76
|
| Rate for Payer: Blue Shield of California EPN |
$150.21
|
| Rate for Payer: Cash Price |
$138.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$200.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$261.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$261.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$261.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$196.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$190.53
|
| Rate for Payer: Heritage Provider Network Senior |
$190.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$146.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$55.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$215.46
|
| Rate for Payer: Multiplan Commercial |
$230.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$123.12
|
| Rate for Payer: TriValley Medical Group Senior |
$123.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$153.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$153.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$261.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$261.63
|
| Rate for Payer: Vantage Medical Group Senior |
$261.63
|
|
|
PYRIMETHAMINE 25 MG TABLET [11246]
|
Facility
|
IP
|
$307.80
|
|
|
Service Code
|
NDC 0480372056
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.71 |
| Max. Negotiated Rate |
$230.85 |
| Rate for Payer: Adventist Health Commercial |
$61.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$198.22
|
| Rate for Payer: Cash Price |
$138.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$166.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$208.38
|
| Rate for Payer: Heritage Provider Network Senior |
$208.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$55.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.95
|
| Rate for Payer: Multiplan Commercial |
$230.85
|
|
|
PYRIMETHAMINE ORAL SOLUTION COMPOUND 2 MG/ML [4080328]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 9994080328
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
PYRIMETHAMINE ORAL SOLUTION COMPOUND 2 MG/ML [4080328]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 9994080328
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
QUETIAPINE 100 MG TABLET [21824]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 4733590488
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
