|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
IP
|
$2.18
|
|
|
Service Code
|
NDC 60687-422-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$2.18
|
|
|
Service Code
|
NDC 60687-422-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.85 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.64
|
| Rate for Payer: Blue Shield of California Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.85
|
| Rate for Payer: Dignity Health Senior |
$1.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| 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 |
$0.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Senior |
$0.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1.85
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 62332-246-31
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.26
|
| 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
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$2.18
|
|
|
Service Code
|
NDC 60687-422-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.85 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.64
|
| Rate for Payer: Blue Shield of California Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.85
|
| Rate for Payer: Dignity Health Senior |
$1.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| 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 |
$0.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Senior |
$0.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1.85
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 62332-246-31
|
| Hospital Charge Code |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.26
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
IP
|
$2.18
|
|
|
Service Code
|
NDC 60687-422-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 60687-797-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 60687-797-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 60687-797-42
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 60687-797-42
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 0121-0646-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| 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 |
$0.05
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 0121-0646-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0802-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$99.52 |
| Max. Negotiated Rate |
$412.39 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$296.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$372.25
|
| Rate for Payer: Heritage Provider Network Senior |
$372.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.46
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$46.08
|
|
|
Service Code
|
NDC 47335-237-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$34.56 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.20
|
| Rate for Payer: Heritage Provider Network Senior |
$31.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
OP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0802-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$99.52 |
| Max. Negotiated Rate |
$467.37 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$293.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$377.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$467.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$302.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$412.39
|
| Rate for Payer: Blue Shield of California Commercial |
$335.41
|
| Rate for Payer: Blue Shield of California EPN |
$268.33
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$357.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$467.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$467.37
|
| Rate for Payer: Dignity Health Senior |
$467.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$351.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$340.36
|
| Rate for Payer: Heritage Provider Network Senior |
$340.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$262.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.89
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$219.94
|
| Rate for Payer: TriValley Medical Group Senior |
$219.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$274.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$274.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$467.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$467.37
|
| Rate for Payer: Vantage Medical Group Senior |
$467.37
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
OP
|
$46.08
|
|
|
Service Code
|
NDC 47335-237-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.56
|
| Rate for Payer: Blue Shield of California Commercial |
$28.11
|
| Rate for Payer: Blue Shield of California EPN |
$22.49
|
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.17
|
| Rate for Payer: Dignity Health Senior |
$39.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.52
|
| Rate for Payer: Heritage Provider Network Senior |
$28.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.26
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.43
|
| Rate for Payer: TriValley Medical Group Senior |
$18.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.17
|
| Rate for Payer: Vantage Medical Group Senior |
$39.17
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0802-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$99.52 |
| Max. Negotiated Rate |
$412.39 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$296.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$372.26
|
| Rate for Payer: Heritage Provider Network Senior |
$372.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.47
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
OP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0802-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$99.52 |
| Max. Negotiated Rate |
$467.38 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$293.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$377.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$467.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$302.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$412.39
|
| Rate for Payer: Blue Shield of California Commercial |
$335.41
|
| Rate for Payer: Blue Shield of California EPN |
$268.33
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$357.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$467.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$467.38
|
| Rate for Payer: Dignity Health Senior |
$467.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$351.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$340.36
|
| Rate for Payer: Heritage Provider Network Senior |
$340.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$262.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.90
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$219.94
|
| Rate for Payer: TriValley Medical Group Senior |
$219.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$274.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$274.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$467.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$467.38
|
| Rate for Payer: Vantage Medical Group Senior |
$467.38
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0801-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$99.52 |
| Max. Negotiated Rate |
$412.39 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$296.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$372.26
|
| Rate for Payer: Heritage Provider Network Senior |
$372.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.47
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$46.08
|
|
|
Service Code
|
NDC 47335-236-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.56
|
| Rate for Payer: Blue Shield of California Commercial |
$28.11
|
| Rate for Payer: Blue Shield of California EPN |
$22.49
|
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.17
|
| Rate for Payer: Dignity Health Senior |
$39.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.52
|
| Rate for Payer: Heritage Provider Network Senior |
$28.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.26
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.43
|
| Rate for Payer: TriValley Medical Group Senior |
$18.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.17
|
| Rate for Payer: Vantage Medical Group Senior |
$39.17
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0801-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$99.52 |
| Max. Negotiated Rate |
$467.37 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$293.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$377.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$467.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$302.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$412.39
|
| Rate for Payer: Blue Shield of California Commercial |
$335.41
|
| Rate for Payer: Blue Shield of California EPN |
$268.33
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$357.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$467.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$467.37
|
| Rate for Payer: Dignity Health Senior |
$467.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$351.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$340.36
|
| Rate for Payer: Heritage Provider Network Senior |
$340.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$262.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.89
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$219.94
|
| Rate for Payer: TriValley Medical Group Senior |
$219.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$274.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$274.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$467.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$467.37
|
| Rate for Payer: Vantage Medical Group Senior |
$467.37
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0801-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$99.52 |
| Max. Negotiated Rate |
$412.39 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$296.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$372.25
|
| Rate for Payer: Heritage Provider Network Senior |
$372.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.46
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$46.08
|
|
|
Service Code
|
NDC 47335-236-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$34.56 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.20
|
| Rate for Payer: Heritage Provider Network Senior |
$31.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0801-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$99.52 |
| Max. Negotiated Rate |
$467.38 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$293.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$377.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$467.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$302.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$412.39
|
| Rate for Payer: Blue Shield of California Commercial |
$335.41
|
| Rate for Payer: Blue Shield of California EPN |
$268.33
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$357.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$467.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$467.38
|
| Rate for Payer: Dignity Health Senior |
$467.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$351.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$340.36
|
| Rate for Payer: Heritage Provider Network Senior |
$340.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$262.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.90
|
| Rate for Payer: Multiplan Commercial |
$412.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$219.94
|
| Rate for Payer: TriValley Medical Group Senior |
$219.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$274.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$274.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$467.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$467.38
|
| Rate for Payer: Vantage Medical Group Senior |
$467.38
|
|
|
AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1.99
|
| Rate for Payer: Heritage Provider Network Senior |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
|
