|
URSODIOL 250 MG TABLET [22660]
|
Facility
OP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-11
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Blue Shield of California Commercial |
$2.61
|
| Rate for Payer: Blue Shield of California EPN |
$2.47
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Senior |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Senior |
$2.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
OP
|
$1.70
|
|
|
Service Code
|
NDC 49884-412-01
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.44
|
| Rate for Payer: Dignity Health Senior |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.44
|
| Rate for Payer: Vantage Medical Group Senior |
$1.44
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
IP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-21
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
IP
|
$1.70
|
|
|
Service Code
|
NDC 49884-412-01
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.17
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
OP
|
$8.98
|
|
|
Service Code
|
NDC 0904-6221-06
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$7.63 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.74
|
| Rate for Payer: Blue Shield of California Commercial |
$5.58
|
| Rate for Payer: Blue Shield of California EPN |
$5.27
|
| Rate for Payer: Cash Price |
$4.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.63
|
| Rate for Payer: Dignity Health Senior |
$7.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.56
|
| Rate for Payer: Heritage Provider Network Senior |
$5.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$6.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.63
|
| Rate for Payer: Vantage Medical Group Senior |
$7.63
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
OP
|
$7.15
|
|
|
Service Code
|
NDC 60687-100-11
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.08 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.36
|
| Rate for Payer: Blue Shield of California Commercial |
$4.44
|
| Rate for Payer: Blue Shield of California EPN |
$4.20
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.08
|
| Rate for Payer: Dignity Health Senior |
$6.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.43
|
| Rate for Payer: Heritage Provider Network Senior |
$4.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.08
|
| Rate for Payer: Vantage Medical Group Senior |
$6.08
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
IP
|
$7.50
|
|
|
Service Code
|
NDC 42806-503-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.15
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.08
|
| Rate for Payer: Heritage Provider Network Senior |
$5.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.88
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
IP
|
$1.26
|
|
|
Service Code
|
NDC 70710-1483-1
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
IP
|
$1.23
|
|
|
Service Code
|
NDC 0591-3159-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| 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
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
IP
|
$8.98
|
|
|
Service Code
|
NDC 0904-6221-06
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$6.74 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.17
|
| Rate for Payer: Cash Price |
$4.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.08
|
| Rate for Payer: Heritage Provider Network Senior |
$6.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$6.74
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
IP
|
$0.95
|
|
|
Service Code
|
NDC 59651-421-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
OP
|
$1.26
|
|
|
Service Code
|
NDC 70710-1483-1
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Senior |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Senior |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
OP
|
$0.95
|
|
|
Service Code
|
NDC 59651-421-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.81
|
| Rate for Payer: Dignity Health Senior |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Senior |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Vantage Medical Group Senior |
$0.81
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
OP
|
$1.50
|
|
|
Service Code
|
NDC 0527-1326-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.88
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.28
|
| Rate for Payer: Dignity Health Senior |
$1.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Vantage Medical Group Senior |
$1.28
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
OP
|
$1.23
|
|
|
Service Code
|
NDC 0591-3159-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.68
|
| 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 |
$0.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: Dignity Health Senior |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| 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 |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
IP
|
$7.15
|
|
|
Service Code
|
NDC 60687-100-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.91
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.84
|
| Rate for Payer: Heritage Provider Network Senior |
$4.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
OP
|
$7.15
|
|
|
Service Code
|
NDC 60687-100-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.08 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.36
|
| Rate for Payer: Blue Shield of California Commercial |
$4.44
|
| Rate for Payer: Blue Shield of California EPN |
$4.20
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.08
|
| Rate for Payer: Dignity Health Senior |
$6.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.43
|
| Rate for Payer: Heritage Provider Network Senior |
$4.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.08
|
| Rate for Payer: Vantage Medical Group Senior |
$6.08
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
OP
|
$7.50
|
|
|
Service Code
|
NDC 42806-503-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$6.38 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.62
|
| Rate for Payer: Blue Shield of California Commercial |
$4.66
|
| Rate for Payer: Blue Shield of California EPN |
$4.40
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.38
|
| Rate for Payer: Dignity Health Senior |
$6.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.64
|
| Rate for Payer: Heritage Provider Network Senior |
$4.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.88
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.38
|
| Rate for Payer: Vantage Medical Group Senior |
$6.38
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
OP
|
$9.20
|
|
|
Service Code
|
NDC 50268-796-11
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$7.82 |
| Rate for Payer: Adventist Health Commercial |
$1.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.90
|
| Rate for Payer: Blue Shield of California Commercial |
$5.71
|
| Rate for Payer: Blue Shield of California EPN |
$5.40
|
| Rate for Payer: Cash Price |
$4.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.82
|
| Rate for Payer: Dignity Health Senior |
$7.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.69
|
| Rate for Payer: Heritage Provider Network Senior |
$5.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.30
|
| Rate for Payer: Multiplan Commercial |
$6.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.82
|
| Rate for Payer: Vantage Medical Group Senior |
$7.82
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
IP
|
$9.20
|
|
|
Service Code
|
NDC 50268-796-11
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$6.90 |
| Rate for Payer: Adventist Health Commercial |
$1.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.32
|
| Rate for Payer: Cash Price |
$4.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.23
|
| Rate for Payer: Heritage Provider Network Senior |
$6.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.30
|
| Rate for Payer: Multiplan Commercial |
$6.90
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
IP
|
$7.15
|
|
|
Service Code
|
NDC 60687-100-11
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.91
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.84
|
| Rate for Payer: Heritage Provider Network Senior |
$4.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
IP
|
$3.06
|
|
|
Service Code
|
NDC 0378-1730-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.10
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
IP
|
$1.50
|
|
|
Service Code
|
NDC 0527-1326-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.03
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
OP
|
$3.06
|
|
|
Service Code
|
NDC 0378-1730-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.90
|
| Rate for Payer: Blue Shield of California EPN |
$1.80
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: Dignity Health Senior |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Vantage Medical Group Senior |
$2.60
|
|
|
URSODIOL ORAL SUSPENSION COMPOUND 60 MG/ML [4080354]
|
Facility
OP
|
$1.50
|
|
|
Service Code
|
NDC 9994-0803-54
|
| Hospital Charge Code |
1715942
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.88
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.28
|
| Rate for Payer: Dignity Health Senior |
$1.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Vantage Medical Group Senior |
$1.28
|
|
