|
OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]
|
Facility
IP
|
$0.30
|
|
|
Service Code
|
NDC 16729-318-01
|
| Hospital Charge Code |
1711989
|
|
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 |
$0.21
|
| 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 Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]
|
Facility
OP
|
$3.67
|
|
|
Service Code
|
NDC 50268-628-15
|
| Hospital Charge Code |
1711989
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Adventist Health Commercial |
$0.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.75
|
| Rate for Payer: Blue Shield of California Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California EPN |
$2.15
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.12
|
| Rate for Payer: Dignity Health Senior |
$3.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Senior |
$2.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$2.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.12
|
| Rate for Payer: Vantage Medical Group Senior |
$3.12
|
|
|
OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]
|
Facility
OP
|
$0.42
|
|
|
Service Code
|
NDC 68382-256-01
|
| Hospital Charge Code |
1711989
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Senior |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| 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 |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]
|
Facility
OP
|
$0.89
|
|
|
Service Code
|
NDC 62175-271-37
|
| Hospital Charge Code |
1711989
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.76
|
| Rate for Payer: Dignity Health Senior |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.43
|
| 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 |
$0.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.76
|
| Rate for Payer: Vantage Medical Group Senior |
$0.76
|
|
|
OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]
|
Facility
OP
|
$0.30
|
|
|
Service Code
|
NDC 16729-318-01
|
| Hospital Charge Code |
1711989
|
|
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 Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]
|
Facility
IP
|
$0.42
|
|
|
Service Code
|
NDC 68382-256-01
|
| Hospital Charge Code |
1711989
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| 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 Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]
|
Facility
IP
|
$0.89
|
|
|
Service Code
|
NDC 62175-271-37
|
| Hospital Charge Code |
1711989
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.61
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| 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 |
$0.67
|
|
|
OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]
|
Facility
IP
|
$3.67
|
|
|
Service Code
|
NDC 50268-628-15
|
| Hospital Charge Code |
1711989
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Adventist Health Commercial |
$0.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.52
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.48
|
| Rate for Payer: Heritage Provider Network Senior |
$2.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$2.75
|
|
|
OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [24470]
|
Facility
OP
|
$0.89
|
|
|
Service Code
|
NDC 62175-270-37
|
| Hospital Charge Code |
1710880
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.76
|
| Rate for Payer: Dignity Health Senior |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.43
|
| 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 |
$0.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.76
|
| Rate for Payer: Vantage Medical Group Senior |
$0.76
|
|
|
OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [24470]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 65162-371-10
|
| Hospital Charge Code |
1710880
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [24470]
|
Facility
OP
|
$0.19
|
|
|
Service Code
|
NDC 65162-371-10
|
| Hospital Charge Code |
1710880
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Senior |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [24470]
|
Facility
IP
|
$3.16
|
|
|
Service Code
|
NDC 50268-627-15
|
| Hospital Charge Code |
1710880
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.17
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Senior |
$2.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
|
|
OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [24470]
|
Facility
IP
|
$3.27
|
|
|
Service Code
|
NDC 51079-722-01
|
| Hospital Charge Code |
1710880
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.45 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.25
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.21
|
| Rate for Payer: Heritage Provider Network Senior |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$2.45
|
|
|
OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [24470]
|
Facility
OP
|
$3.16
|
|
|
Service Code
|
NDC 50268-627-15
|
| Hospital Charge Code |
1710880
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.69
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.69
|
| Rate for Payer: Dignity Health Senior |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Senior |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.69
|
| Rate for Payer: Vantage Medical Group Senior |
$2.69
|
|
|
OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [24470]
|
Facility
OP
|
$3.27
|
|
|
Service Code
|
NDC 51079-722-01
|
| Hospital Charge Code |
1710880
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.78 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.78
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.45
|
| Rate for Payer: Blue Shield of California Commercial |
$2.03
|
| Rate for Payer: Blue Shield of California EPN |
$1.92
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.78
|
| Rate for Payer: Dignity Health Senior |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Senior |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$2.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.78
|
| Rate for Payer: Vantage Medical Group Senior |
$2.78
|
|
|
OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [24470]
|
Facility
IP
|
$0.89
|
|
|
Service Code
|
NDC 62175-270-37
|
| Hospital Charge Code |
1710880
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.61
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| 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 |
$0.67
|
|
|
OXYCHLOROSENE SODIUM TOPICAL POWDER FOR SOLUTION [207355]
|
Facility
IP
|
$3.36
|
|
|
Service Code
|
NDC 0327-0001-10
|
| Hospital Charge Code |
1743758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.31
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Senior |
$2.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
|
|
OXYCHLOROSENE SODIUM TOPICAL POWDER FOR SOLUTION [207355]
|
Facility
OP
|
$3.36
|
|
|
Service Code
|
NDC 0327-0001-10
|
| Hospital Charge Code |
1743758
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.52
|
| Rate for Payer: Blue Shield of California Commercial |
$2.09
|
| Rate for Payer: Blue Shield of California EPN |
$1.97
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.86
|
| Rate for Payer: Dignity Health Senior |
$2.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Senior |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.86
|
| Rate for Payer: Vantage Medical Group Senior |
$2.86
|
|
|
OXYCODONE 10 MG/0.5 ML ORAL SYRINGE (FOR ORAL USE ONLY) [215181]
|
Facility
OP
|
$4.49
|
|
|
Service Code
|
NDC 68094-801-58
|
| Hospital Charge Code |
NDG215181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.37
|
| Rate for Payer: Blue Shield of California Commercial |
$2.79
|
| Rate for Payer: Blue Shield of California EPN |
$2.64
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.82
|
| Rate for Payer: Dignity Health Senior |
$3.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.78
|
| Rate for Payer: Heritage Provider Network Senior |
$2.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$3.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.82
|
| Rate for Payer: Vantage Medical Group Senior |
$3.82
|
|
|
OXYCODONE 10 MG/0.5 ML ORAL SYRINGE (FOR ORAL USE ONLY) [215181]
|
Facility
IP
|
$4.49
|
|
|
Service Code
|
NDC 68094-801-01
|
| Hospital Charge Code |
NDG215181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.08
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.04
|
| Rate for Payer: Heritage Provider Network Senior |
$3.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$3.37
|
|
|
OXYCODONE 10 MG/0.5 ML ORAL SYRINGE (FOR ORAL USE ONLY) [215181]
|
Facility
OP
|
$4.49
|
|
|
Service Code
|
NDC 68094-801-01
|
| Hospital Charge Code |
NDG215181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.37
|
| Rate for Payer: Blue Shield of California Commercial |
$2.79
|
| Rate for Payer: Blue Shield of California EPN |
$2.64
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.82
|
| Rate for Payer: Dignity Health Senior |
$3.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.78
|
| Rate for Payer: Heritage Provider Network Senior |
$2.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$3.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.82
|
| Rate for Payer: Vantage Medical Group Senior |
$3.82
|
|
|
OXYCODONE 10 MG/0.5 ML ORAL SYRINGE (FOR ORAL USE ONLY) [215181]
|
Facility
IP
|
$4.49
|
|
|
Service Code
|
NDC 68094-801-58
|
| Hospital Charge Code |
NDG215181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.08
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.04
|
| Rate for Payer: Heritage Provider Network Senior |
$3.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$3.37
|
|
|
OXYCODONE 10 MG TABLET [87795]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 10702-056-01
|
| Hospital Charge Code |
ERX87795
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
OXYCODONE 10 MG TABLET [87795]
|
Facility
OP
|
$0.15
|
|
|
Service Code
|
NDC 42858-002-01
|
| Hospital Charge Code |
ERX87795
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: Dignity Health Senior |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
OXYCODONE 10 MG TABLET [87795]
|
Facility
IP
|
$0.15
|
|
|
Service Code
|
NDC 42858-002-01
|
| Hospital Charge Code |
ERX87795
|
|
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
|
|
