|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]
|
Facility
IP
|
$2.27
|
|
|
Service Code
|
NDC 0406-0523-23
|
| Hospital Charge Code |
1730174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]
|
Facility
OP
|
$0.59
|
|
|
Service Code
|
NDC 0406-0523-01
|
| Hospital Charge Code |
1730174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.50
|
| Rate for Payer: Dignity Health Senior |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Vantage Medical Group Senior |
$0.50
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]
|
Facility
OP
|
$2.27
|
|
|
Service Code
|
NDC 0406-0523-23
|
| Hospital Charge Code |
1730174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$1.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: Dignity Health Senior |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.93
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]
|
Facility
IP
|
$0.59
|
|
|
Service Code
|
NDC 0406-0523-01
|
| Hospital Charge Code |
1730174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]
|
Facility
OP
|
$2.16
|
|
|
Service Code
|
NDC 68308-480-47
|
| Hospital Charge Code |
1730174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.48
|
| 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 |
$1.62
|
| Rate for Payer: Blue Shield of California Commercial |
$1.34
|
| Rate for Payer: Blue Shield of California EPN |
$1.27
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.40
|
| 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 |
$1.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.34
|
| Rate for Payer: Heritage Provider Network Senior |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.04
|
| 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 |
$1.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.84
|
| Rate for Payer: Vantage Medical Group Senior |
$1.84
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 42858-102-01
|
| Hospital Charge Code |
1730102
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 42858-102-01
|
| Hospital Charge Code |
1730102
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]
|
Facility
OP
|
$0.22
|
|
|
Service Code
|
NDC 53746-203-01
|
| Hospital Charge Code |
1730102
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]
|
Facility
IP
|
$0.22
|
|
|
Service Code
|
NDC 53746-203-01
|
| Hospital Charge Code |
1730102
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]
|
Facility
OP
|
$0.34
|
|
|
Service Code
|
NDC 0904-7093-61
|
| Hospital Charge Code |
1730102
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]
|
Facility
IP
|
$0.34
|
|
|
Service Code
|
NDC 0904-7093-61
|
| Hospital Charge Code |
1730102
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208667]
|
Facility
OP
|
$6.03
|
|
|
Service Code
|
NDC 59011-410-20
|
| Hospital Charge Code |
1730114
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.52
|
| Rate for Payer: Blue Shield of California Commercial |
$3.74
|
| Rate for Payer: Blue Shield of California EPN |
$3.54
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Senior |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.73
|
| Rate for Payer: Heritage Provider Network Senior |
$3.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208667]
|
Facility
IP
|
$6.03
|
|
|
Service Code
|
NDC 59011-410-20
|
| Hospital Charge Code |
1730114
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.14
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.08
|
| Rate for Payer: Heritage Provider Network Senior |
$4.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
|
|
OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208669]
|
Facility
OP
|
$11.23
|
|
|
Service Code
|
NDC 59011-420-20
|
| Hospital Charge Code |
1730115
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$9.55 |
| Rate for Payer: Adventist Health Commercial |
$2.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.42
|
| Rate for Payer: Blue Shield of California Commercial |
$6.97
|
| Rate for Payer: Blue Shield of California EPN |
$6.59
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.55
|
| Rate for Payer: Dignity Health Senior |
$9.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.95
|
| Rate for Payer: Heritage Provider Network Senior |
$6.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.55
|
| Rate for Payer: Vantage Medical Group Senior |
$9.55
|
|
|
OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208669]
|
Facility
IP
|
$11.23
|
|
|
Service Code
|
NDC 59011-420-20
|
| Hospital Charge Code |
1730115
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$8.42 |
| Rate for Payer: Adventist Health Commercial |
$2.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.72
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.60
|
| Rate for Payer: Heritage Provider Network Senior |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
|
|
OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208669]
|
Facility
IP
|
$9.00
|
|
|
Service Code
|
NDC 69238-2296-1
|
| Hospital Charge Code |
1730115
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$6.75 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.18
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.09
|
| Rate for Payer: Heritage Provider Network Senior |
$6.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
|
|
OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208669]
|
Facility
OP
|
$9.00
|
|
|
Service Code
|
NDC 69238-2296-1
|
| Hospital Charge Code |
1730115
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.75
|
| Rate for Payer: Blue Shield of California Commercial |
$5.59
|
| Rate for Payer: Blue Shield of California EPN |
$5.28
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.65
|
| Rate for Payer: Dignity Health Senior |
$7.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.57
|
| Rate for Payer: Heritage Provider Network Senior |
$5.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.65
|
| Rate for Payer: Vantage Medical Group Senior |
$7.65
|
|
|
OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208671]
|
Facility
OP
|
$19.22
|
|
|
Service Code
|
NDC 59011-440-20
|
| Hospital Charge Code |
1731015
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$16.34 |
| Rate for Payer: Adventist Health Commercial |
$3.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.57
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.42
|
| Rate for Payer: Blue Shield of California Commercial |
$11.94
|
| Rate for Payer: Blue Shield of California EPN |
$11.28
|
| Rate for Payer: Cash Price |
$8.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.34
|
| Rate for Payer: Dignity Health Senior |
$16.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.90
|
| Rate for Payer: Heritage Provider Network Senior |
$11.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: Multiplan Commercial |
$14.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.34
|
| Rate for Payer: Vantage Medical Group Senior |
$16.34
|
|
|
OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208671]
|
Facility
IP
|
$19.22
|
|
|
Service Code
|
NDC 59011-440-20
|
| Hospital Charge Code |
1731015
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$14.42 |
| Rate for Payer: Adventist Health Commercial |
$3.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.20
|
| Rate for Payer: Cash Price |
$8.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.01
|
| Rate for Payer: Heritage Provider Network Senior |
$13.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: Multiplan Commercial |
$14.42
|
|
|
OXYCODONE ER 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208673]
|
Facility
OP
|
$33.56
|
|
|
Service Code
|
NDC 59011-480-20
|
| Hospital Charge Code |
1731012
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$28.53 |
| Rate for Payer: Adventist Health Commercial |
$6.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.17
|
| Rate for Payer: Blue Shield of California Commercial |
$20.84
|
| Rate for Payer: Blue Shield of California EPN |
$19.70
|
| Rate for Payer: Cash Price |
$15.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.53
|
| Rate for Payer: Dignity Health Senior |
$28.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.77
|
| Rate for Payer: Heritage Provider Network Senior |
$20.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.39
|
| Rate for Payer: Multiplan Commercial |
$25.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.53
|
| Rate for Payer: Vantage Medical Group Senior |
$28.53
|
|
|
OXYCODONE ER 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208673]
|
Facility
IP
|
$33.56
|
|
|
Service Code
|
NDC 59011-480-20
|
| Hospital Charge Code |
1731012
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$25.17 |
| Rate for Payer: Adventist Health Commercial |
$6.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.06
|
| Rate for Payer: Cash Price |
$15.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.72
|
| Rate for Payer: Heritage Provider Network Senior |
$22.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.39
|
| Rate for Payer: Multiplan Commercial |
$25.17
|
|
|
OXYMETAZOLINE 0.05 % NASAL MIST [114934]
|
Facility
IP
|
$0.48
|
|
|
Service Code
|
NDC 2390002326
|
| Hospital Charge Code |
NDG114934
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
|
|
OXYMETAZOLINE 0.05 % NASAL MIST [114934]
|
Facility
OP
|
$0.48
|
|
|
Service Code
|
NDC 2390002326
|
| Hospital Charge Code |
NDG114934
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Senior |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| 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 Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
OXYMETAZOLINE 0.05 % NASAL MIST [114934]
|
Facility
IP
|
$0.45
|
|
|
Service Code
|
NDC 11523-1159-1
|
| Hospital Charge Code |
NDG114934
|
|
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
|
|
|
OXYMETAZOLINE 0.05 % NASAL MIST [114934]
|
Facility
OP
|
$0.45
|
|
|
Service Code
|
NDC 11523-1159-1
|
| Hospital Charge Code |
NDG114934
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: Dignity Health Senior |
$0.38
|
| 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 |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
