|
PYRAZINAMIDE ORAL SUSPENSION COMPOUND 100 MG/ML [4080326]
|
Facility
OP
|
$6.32
|
|
|
Service Code
|
NDC 9994-0803-26
|
| Hospital Charge Code |
1715093
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$5.37 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.74
|
| Rate for Payer: Blue Shield of California Commercial |
$3.92
|
| Rate for Payer: Blue Shield of California EPN |
$3.71
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.37
|
| Rate for Payer: Dignity Health Senior |
$5.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.91
|
| Rate for Payer: Heritage Provider Network Senior |
$3.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$4.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.37
|
| Rate for Payer: Vantage Medical Group Senior |
$5.37
|
|
|
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION [11237]
|
Facility
IP
|
$18.43
|
|
|
Service Code
|
NDC 0781-3040-95
|
| Hospital Charge Code |
1721076
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$13.82 |
| Rate for Payer: Adventist Health Commercial |
$3.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.66
|
| Rate for Payer: Cash Price |
$8.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.48
|
| Rate for Payer: Heritage Provider Network Senior |
$12.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.61
|
| Rate for Payer: Multiplan Commercial |
$13.82
|
|
|
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION [11237]
|
Facility
OP
|
$18.43
|
|
|
Service Code
|
NDC 0781-3040-72
|
| Hospital Charge Code |
1721076
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$15.67 |
| Rate for Payer: Adventist Health Commercial |
$3.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$15.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.82
|
| Rate for Payer: Blue Shield of California Commercial |
$11.45
|
| Rate for Payer: Blue Shield of California EPN |
$10.82
|
| Rate for Payer: Cash Price |
$8.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.67
|
| Rate for Payer: Dignity Health Senior |
$15.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.41
|
| Rate for Payer: Heritage Provider Network Senior |
$11.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.61
|
| Rate for Payer: Multiplan Commercial |
$13.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.67
|
| Rate for Payer: Vantage Medical Group Senior |
$15.67
|
|
|
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION [11237]
|
Facility
IP
|
$18.43
|
|
|
Service Code
|
NDC 0781-3040-72
|
| Hospital Charge Code |
1721076
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$13.82 |
| Rate for Payer: Adventist Health Commercial |
$3.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.66
|
| Rate for Payer: Cash Price |
$8.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.48
|
| Rate for Payer: Heritage Provider Network Senior |
$12.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.61
|
| Rate for Payer: Multiplan Commercial |
$13.82
|
|
|
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION [11237]
|
Facility
OP
|
$18.43
|
|
|
Service Code
|
NDC 0781-3040-95
|
| Hospital Charge Code |
1721076
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$15.67 |
| Rate for Payer: Adventist Health Commercial |
$3.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$15.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.82
|
| Rate for Payer: Blue Shield of California Commercial |
$11.45
|
| Rate for Payer: Blue Shield of California EPN |
$10.82
|
| Rate for Payer: Cash Price |
$8.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.67
|
| Rate for Payer: Dignity Health Senior |
$15.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.41
|
| Rate for Payer: Heritage Provider Network Senior |
$11.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.61
|
| Rate for Payer: Multiplan Commercial |
$13.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.67
|
| Rate for Payer: Vantage Medical Group Senior |
$15.67
|
|
|
PYRIDOSTIGMINE BROMIDE 60 MG/5 ML ORAL SYRUP [11238]
|
Facility
IP
|
$4.06
|
|
|
Service Code
|
NDC 0187-3012-20
|
| Hospital Charge Code |
1715939
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.79
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.75
|
| Rate for Payer: Heritage Provider Network Senior |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.04
|
|
|
PYRIDOSTIGMINE BROMIDE 60 MG/5 ML ORAL SYRUP [11238]
|
Facility
OP
|
$4.06
|
|
|
Service Code
|
NDC 0187-3012-20
|
| Hospital Charge Code |
1715939
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.04
|
| Rate for Payer: Blue Shield of California Commercial |
$2.52
|
| Rate for Payer: Blue Shield of California EPN |
$2.38
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.45
|
| Rate for Payer: Dignity Health Senior |
$3.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.51
|
| Rate for Payer: Heritage Provider Network Senior |
$2.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.45
|
| Rate for Payer: Vantage Medical Group Senior |
$3.45
|
|
|
PYRIDOSTIGMINE BROMIDE 60 MG TABLET [11239]
|
Facility
OP
|
$1.22
|
|
|
Service Code
|
NDC 71930-028-90
|
| Hospital Charge Code |
1710447
|
|
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 Gatekeeper |
$0.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| 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
IP
|
$1.22
|
|
|
Service Code
|
NDC 71930-028-90
|
| Hospital Charge Code |
1710447
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
|
|
PYRIDOSTIGMINE BROMIDE 60 MG TABLET [11239]
|
Facility
IP
|
$1.22
|
|
|
Service Code
|
NDC 68682-302-10
|
| Hospital Charge Code |
1710447
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
|
|
PYRIDOSTIGMINE BROMIDE 60 MG TABLET [11239]
|
Facility
OP
|
$1.22
|
|
|
Service Code
|
NDC 68382-659-06
|
| Hospital Charge Code |
1710447
|
|
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 Gatekeeper |
$0.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| 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
IP
|
$1.22
|
|
|
Service Code
|
NDC 68382-659-06
|
| Hospital Charge Code |
1710447
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
|
|
PYRIDOSTIGMINE BROMIDE 60 MG TABLET [11239]
|
Facility
OP
|
$1.22
|
|
|
Service Code
|
NDC 68682-302-10
|
| Hospital Charge Code |
1710447
|
|
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 Gatekeeper |
$0.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| 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
OP
|
$24.83
|
|
|
Service Code
|
NDC 68682-301-30
|
| Hospital Charge Code |
1710454
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.49 |
| Max. Negotiated Rate |
$21.11 |
| Rate for Payer: Adventist Health Commercial |
$4.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$21.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.62
|
| Rate for Payer: Blue Shield of California Commercial |
$15.42
|
| Rate for Payer: Blue Shield of California EPN |
$14.58
|
| Rate for Payer: Cash Price |
$11.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.11
|
| Rate for Payer: Dignity Health Senior |
$21.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.37
|
| Rate for Payer: Heritage Provider Network Senior |
$15.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.21
|
| Rate for Payer: Multiplan Commercial |
$18.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.11
|
| Rate for Payer: Vantage Medical Group Senior |
$21.11
|
|
|
PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE [11240]
|
Facility
IP
|
$24.83
|
|
|
Service Code
|
NDC 68682-301-30
|
| Hospital Charge Code |
1710454
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.49 |
| Max. Negotiated Rate |
$18.62 |
| Rate for Payer: Adventist Health Commercial |
$4.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.06
|
| Rate for Payer: Cash Price |
$11.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.81
|
| Rate for Payer: Heritage Provider Network Senior |
$16.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.21
|
| Rate for Payer: Multiplan Commercial |
$18.62
|
|
|
PYRIDOXINE ORAL SOLUTION (IV FORM) 100 MG/ML [4080441]
|
Facility
IP
|
$10.79
|
|
|
Service Code
|
NDC 9994-0804-41
|
| Hospital Charge Code |
1715004
|
|
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 |
$7.41
|
| 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 Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$8.09
|
|
|
PYRIDOXINE ORAL SOLUTION (IV FORM) 100 MG/ML [4080441]
|
Facility
OP
|
$10.79
|
|
|
Service Code
|
NDC 9994-0804-41
|
| Hospital Charge Code |
1715004
|
|
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 Gatekeeper |
$5.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.09
|
| Rate for Payer: Blue Shield of California Commercial |
$6.70
|
| Rate for Payer: Blue Shield of California EPN |
$6.33
|
| 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 Senior |
$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 Permanente of CA Commercial |
$5.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$8.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.17
|
| Rate for Payer: Vantage Medical Group Senior |
$9.17
|
|
|
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION [6744]
|
Facility
IP
|
$22.87
|
|
|
Service Code
|
CPT J3415
|
| Hospital Charge Code |
1720634
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.14 |
| Max. Negotiated Rate |
$17.15 |
| Rate for Payer: Adventist Health Commercial |
$4.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.71
|
| Rate for Payer: Cash Price |
$10.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.48
|
| Rate for Payer: Heritage Provider Network Senior |
$15.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.72
|
| Rate for Payer: Multiplan Commercial |
$17.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.64
|
|
|
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION [6744]
|
Facility
OP
|
$22.87
|
|
|
Service Code
|
CPT J3415
|
| Hospital Charge Code |
1720634
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.14 |
| Max. Negotiated Rate |
$36.41 |
| Rate for Payer: Adventist Health Commercial |
$4.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$36.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.96
|
| Rate for Payer: Blue Shield of California Commercial |
$16.90
|
| Rate for Payer: Blue Shield of California EPN |
$16.90
|
| Rate for Payer: Cash Price |
$10.29
|
| Rate for Payer: Cash Price |
$10.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.44
|
| Rate for Payer: Dignity Health Senior |
$19.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.59
|
| Rate for Payer: Heritage Provider Network Senior |
$10.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.72
|
| Rate for Payer: Multiplan Commercial |
$17.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.44
|
| Rate for Payer: Vantage Medical Group Senior |
$19.44
|
|
|
PYRIDOXINE (VITAMIN B6) 100 MG TABLET [6745]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 8770140730
|
| Hospital Charge Code |
1711339
|
|
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 Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
PYRIDOXINE (VITAMIN B6) 100 MG TABLET [6745]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 8770140730
|
| Hospital Charge Code |
1711339
|
|
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 Permanente of CA 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) 25 MG TABLET [6746]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 536440601
|
| Hospital Charge Code |
ERX6746
|
|
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 Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| 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 536440601
|
| Hospital Charge Code |
ERX6746
|
|
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 Permanente of CA 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
OP
|
$0.28
|
|
|
Service Code
|
NDC 5026885811
|
| Hospital Charge Code |
1710834
|
|
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 Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| 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 |
1710834
|
|
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 |
$0.19
|
| 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 Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
